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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850456
Report Date: 03/02/2026
Date Signed: 03/02/2026 03:30:05 PM

Document Has Been Signed on 03/02/2026 03:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:LOVE CIRCLE HOME CAREFACILITY NUMBER:
565850456
ADMINISTRATOR/
DIRECTOR:		PANTIG,JENNIFERFACILITY TYPE:
740
ADDRESS:1936 EDGEWOOD DRIVETELEPHONE:
(951) 454-5346
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 4DATE:
03/02/2026
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Jennifer PantigTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a post-licensing visit today. Upon arrival, there were two (2) staff members and four (4) residents present. The LPA met with facility staff who contacted Administrator, Jennifer Pantig and at this time the reason for the visit was explained. The Administrator arrived at the facility during the inspection. Entrance interview.

Beginning at 10:02 AM, the LPA along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. The LPA observed knives and sharps in a locked drawer at the time of the visit. Cleaning supplies were observed under the kitchen sink locked and inaccessible. Refrigerator and pantry were checked for expirations dates.

COMMON AREAS: This includes the two (2) living rooms and dining area. The LPA observed the living rooms to be clean and properly furnished at the time of the visit. The dining area was observed to be equipped with adequate seating for resident use. All furniture throughout the facility was observed to be clean and in good repair.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LOVE CIRCLE HOME CARE
FACILITY NUMBER: 565850456
VISIT DATE: 03/02/2026
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Report Continued from LIC 809...

There is a fireplace adequately screened at the time of the visit. The LPA observed two (2) fire extinguishers with a purchase date of 08/07/2025. The LPA observed a working telephone on premises. No tripping hazards were observed inside or out.

BEDROOMS: There are five (5) bedrooms in the facility for resident use; four (4) are designated for single occupancy, and one (1) is designated for shared / double occupancy. All resident rooms were observed to be furnished with appropriate furnishings and sufficient lighting. Additional clean linens and towel were observed in a storage closet by the hallway. The LPA observed personal hygiene items locked and inaccessible to residents in care at the time of the visit.

BATHROOMS: There are two (2) bathrooms at the facility for resident use. One (1) is designated as a private resident bathroom, and one (1) is designated as a shared/common resident bathroom. All resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Beginning at 10:10 AM, the water temperature was measured in resident bathrooms, and they measured within the required range of 105 – 120 degrees Fahrenheit.

OUTDOOR SPACE: The LPA observed an adequate shaded seating area with appropriate outdoor furniture for resident use. The facility has one (1) self-latching gate for emergency use. All passageways were observed to be clear of any obstructions. No bodies of water noted at the time of the visit.

GARAGE: The garage is attached to the house. Washer and dryer were observed inside. Laundry detergents and cleaning supplies were observed inaccessible to residents at the time of the visit. The LPA observed an adequate amount of emergency food and water at the time of the visit.

RECORD REVIEW: Record review began at 10:25 AM. Four (4) resident files were reviewed for but not limited to; signed admissions agreement, medical assessment, negative tb test results, consent for treatment form, pre-appraisal, appraisal, needs & service plan, and personal rights.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LOVE CIRCLE HOME CARE
FACILITY NUMBER: 565850456
VISIT DATE: 03/02/2026
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Report Continued from LIC 809C...

Six (6) staff files were reviewed for but not limited to; personnel record, health screening with negative tb test result, fingerprint clearance, first aid / cpr certification, and annual staff training. Files were in order. Administrator Certificate valid until 01/15/2027.

MEDICATION REVIEW: Medication review began at approximately 12:50 PM. Medications are centrally stored and kept in a locked kitchen cabinet. Medications for two (2) residents were observed. Start dates noted and actual start dates did not match. LPA was unable to verify pill count. The Administrator will review centrally stored medications and records to match correct dates.

EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed facility's emergency disaster plan. The facility’s emergency disaster plan is up to date and is adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 02/13/2026.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC809-D).

Exit interview conducted. A copy of report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/02/2026 03:30 PM - It Cannot Be Edited


Created By: Martha Arroyo On 03/02/2026 at 03:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LOVE CIRCLE HOME CARE
FACILITY NUMBER: 565850456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, the licensee did not comply with the section cited above as start dates on the centrally stored records did not match actualy start dates, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2026
Plan of Correction
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The Licensee has agreed to review medications and centrally stored records so that all information is accurate and up to date and send proof to CCL to later than POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Martha Arroyo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2026


LIC809 (FAS) - (06/04)
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