565850596-12-1-2025-29-AS-MARO-DNXVYS-20251201155138

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850596
Report Date: 12/01/2025
Date Signed: 12/01/2025 03:52:39 PM

Document Has Been Signed on 12/01/2025 03:52 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:	MYMDCARE SENIOR LIVING		FACILITY NUMBER:	565850596
ADMINISTRATOR/ DIRECTOR:	MARRI, MAAYA		FACILITY TYPE:	740
ADDRESS:	2267 GLORYETTE AVE		TELEPHONE:	(434) 227-0350
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 6		CENSUS: 6	DATE:	12/01/2025
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	Maaya Marri		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a post licensing visit. Upon arrival, the LPA was greeted by staff who then contacted the Administrator telephonically. The Administrator, Maaya Marri arrived at approx. 11:00 a.m., and the reason for the visit was explained. Entrance interview.

Beginning at 11:05 a.m., LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

The kitchen/food service area was observed at approx. 11:25 a.m. Knives and sharps were observed in a locked drawer. Cleaning supplies and other chemicals are kept locked under the sink area. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates.

There are five (5) bedrooms in the facility for resident use; four (4) bedrooms are designated as private, single occupancy rooms, and (1) bedroom is designated as a double, shared occupancy room. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. Additional clean linens and towels are available for resident use in a hallway closet. There are two (2) restrooms in the facility. Restrooms were observed to be clean and in sanitary condition. Grab bars and slip resistant floor were observed. Restrooms were sufficiently stocked with supplies and paper towels.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2025

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: MYMDCARE SENIOR LIVING	FACILITY NUMBER: 565850596
	VISIT DATE: 12/01/2025

NARRATIVE

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Report Continued from LIC 809...

The hot water temperature was measured starting at 11:18 a.m., and they measured outside of the required range of 105 – 120 degrees Fahrenheit. The Administrator adjusted the water temperature during today’s inspection.

The LPA observed the garage which was inaccessible to residents at the time of the visit. There is a washer and dryer inside the garage. Toxins and detergents were observed locked and inaccessible at the time of the visit. A sufficient supply of emergency food and water was observed.

The LPA observed the common area. This includes the living room and a dining room. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The fire extinguisher was observed to be new with a purchase date of 08/27/2025. LPA observed required postings throughout the common space. Activities were observed in the common areas. There is a functioning telephone on the premises. Fireplace was observed to be adequately covered at the time of the visit.

The backyard has a covered patio area with shade, patio furniture including tables and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. No bodies of water noted at the time of the visit.

Record review began at approx. 11:40 a.m. Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, PRN authorization letters, and current needs and services plan. Files were complete.

Three (3) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. The Administrator’s Certificate is valid until March 2027.

At approx. 12:40 p.m., LPA reviewed Guardian and observed that Staff #1 (S1) has started the criminal record clearance, but it is still in process and Staff #2 (S2) does not show a criminal record clearance on file. Interviews revealed that S1 and S2 have been working at the facility for one (1) day. S1 and S2 left during today’s inspection.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2025

LIC809 (FAS) - (06/04)

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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: MYMDCARE SENIOR LIVING	FACILITY NUMBER: 565850596
	VISIT DATE: 12/01/2025

NARRATIVE

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Report Continued from LIC 809C...

During today’s visit, LPA reviewed the facility’s emergency disaster plan. Emergency disaster drill are being conducted quarterly as per regulation; last one conducted on 09/01/2025.

Medications are centrally stored in a cabinet adjacent to the living room. Medications appear to be administered as prescribed at the time of the visit.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code.

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: 12/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/01/2025 03:52 PM - It Cannot Be Edited

Created By: Martha Arroyo On 12/01/2025 at 01:24 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: MYMDCARE SENIOR LIVING	FACILITY NUMBER: 565850596
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.17(b)(1)(C)

Licensing

(C) Any person who provides client assistance in dressing, grooming, bathing, or personal hygiene. Any nurse assistant or home health aide meeting the requirements of Section 1338.5 or 1736.6, respectively, who is not employed, retained, or contracted by the licensee, and who has been certified or recertified on or after July 1, 1998, shall be deemed to meet the criminal record clearance requirements of this section. A certified nurse assistant and certified home health aide who will be providing client assistance and who falls under this exemption shall provide one copy of their current certification, prior to providing care, to the residential care facility for the elderly. The facility shall maintain the copy of the certification on file as long as the care is being provided by the certified nurse assistant or certified home health aide at the facility. Nothing in this paragraph restricts the right of the department to exclude a certified nurse assistant or certified home health aide from a licensed residential care facility for the elderly pursuant to Section 1569.58. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as S1 and S2 are not finger print cleared through Guardian, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/01/2025
	Plan of Correction
1 2 3 4	The Licensee had a staff that is finger print cleared arrive to the facility during the inspection. A $200 civil penalty has been assesed today.

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: 12/01/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2025

LIC809 (FAS) - (06/04)

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