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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850614
Report Date: 06/16/2025
Date Signed: 06/17/2025 08:14:59 AM

Document Has Been Signed on 06/17/2025 08:14 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CLUBHOUSE HAVEN, THEFACILITY NUMBER:
565850614
ADMINISTRATOR/
DIRECTOR:		CACAL, JOCELYNFACILITY TYPE:
740
ADDRESS:4104 CLUBHOUSE DRIVETELEPHONE:
(512) 592-9001
CITY:SOMISSTATE: CAZIP CODE:
93066
CAPACITY: 6CENSUS: 0DATE:
06/16/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH: Jocelyn CacalTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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At 9:45 A.M. Licensing Program Analyst (LPA) Valeria Conway conducted an announced Pre-Licensing Inspection to the above listed facility. Upon arrival LPA met with Administrator, Jocelyn Cacal. The proposed physical plant is a one (1) story single family dwelling located in a residential neighborhood of Somis, CA. This facility will be housing residents with dementia. There are no client residing in the facility at the moment. Entrance interview conducted.

An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 12/09/2024. On 05/06/2025 a Fire Clearance was approved for a maximum capacity of six (6) non-ambulatory residents, including one (1) bedridden resident in Room #5. The facility is equipped with two (2) fire doors to enhance the resident safety and prevent the spread of fire. One (1) fire door separates all resident rooms from the common areas, and the second fire door is installed at the entrance of Room #5 which is designated for a non-ambulatory or a bedridden resident. At the time of the visit, the LPA did not observe a magnet or approved device in place to hold the fire doors open. LPA informed the Administrator that fire doors must not be propped open with door stoppers or any other items that could obstruct their automatic closure in the event of an emergency. The Administrator acknowledged this requirement and stated that both fire doors will remain closed at all times. This pending facility has a dementia care program and a granted hospice waiver for 6 (six) residents.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CLUBHOUSE HAVEN, THE
FACILITY NUMBER: 565850614
VISIT DATE: 06/16/2025
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Continued from LIC 809

At 10:00 A.M. LPA along with Administrator conducted a facility plant tour for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following observed:

Fire extinguishers are fully charged and recently purchased on 06/10/2025. Smoke detectors are hard wired throughout the facility. Fire alarms/carbon monoxide detectors were tested at 11:10 A.M. and were functional at the time of the visit. LPA observed all required postings on the facility wall, a revised Emergency and Disaster Plan and a Plan of Operation is in use.

BEDROOMS: The facility consists of six (6) private resident bedrooms and one (1) staff room. There was a model furnished bedroom equipped and supplied with appropriate furniture including but not limited to a bed, a chair, a night stan, a lamp and a chest of drawers, bedding, and linens. No client bedroom will be used as a public or general passageway to another room, bath, or toilet. There were no visible hazards or discrepancies observed. Auditorial signal system was observed in each door around the facility. LPA observed that Rooms #2, #4, #5 and #6 did not have curtains or window coverings on the windows to ensure the privacy of residents occupying the bedroom. Additionally, Room #5 was observed to be missing a curtain or a window covering on the exit door. During today’s visit, rails and curtains were installed.

BATHROOMS: The facility consist of seven (7) bathrooms. Three (3) are shared bathrooms and four (4) are located inside Room #2, #3, #4 and #5. LPA observed toilets and handwashing stations to be in operation condition. Solid waste containers are in good repair and have tight-fitting covers. Additionally, LPA observed all bathrooms to have grab bars and slip-resistant floors and mats. Between 10:20 A.M. and 10:40 A.M. hot water temperatures were measured in all bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit. Facility provides each resident privacy and personal accommodations.

Continued from LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CLUBHOUSE HAVEN, THE
FACILITY NUMBER: 565850614
VISIT DATE: 06/16/2025
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Continued from LIC 809-C

COMMON AREAS: These include the Foyer, Entertainment Room, Living Room and Dining Room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. At the time of the visit, LPA observed locked cabinets located in the entertainment room designated to store staff and resident files, residents’ medications and first aid kit. Facility will properly document medication on the Centrally Store Medication and Destruction log. The facility has a fireplace, at the time of the visit, LPA observed the fireplace properly screened. Facility has installed internet service for resident use. Facility has enough space to store clean common linen items such as bed sheets, towels, pillowcases, and mattress pads. LPA observed night lights in all hallways and passages. Facility has an auditory signal system in place at the time of the visit. The facility maintained a comfortable temperature of 72 degrees Fahrenheit.

KITCHEN: Appliances and fixtures appeared clean and functional. At the time of the visit, LPA observed a sufficient amount of dining and cookware. LPA observed a sufficient amount of perishable food. Administrator is aware that food supply shall accommodate a maximum capacity of six (6) residents and facility staff for seven (7) days. Sharps and knives will be stored in a locked kitchen drawer located to the left of the dishwasher. There were no visible immediate hazards observed. At 10:45 A.M. hot water temperature measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit. LPA observed a working phone available for resident’s use.



LAUNDRY ROOM: LPA observed a washer and a dryer machine and a sufficient amount of emergency water. Furthermore, LPA observed several locked cabinets where chemical, hygiene products and cleaning supplies will be stored.

SURROUNDING GROUNDS: Garden and yard are easily accessible to residents, and they are sufficient in size, comfortable and appropriately equipped for outdoor use. There was a shaded area with proper furniture for outdoor use. LPA observed one (1) self-closing and latching side gate. Additionally, LPA observed sufficient space to accommodate outdoor activities for residents. There are no bodies of water on the premises.

Continued from LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CLUBHOUSE HAVEN, THE
FACILITY NUMBER: 565850614
VISIT DATE: 06/16/2025
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Continued from LIC 809-C

GARAGE: LPA observed a detached locked garage, which contains hardware supplies, extra mobility devices and tools.

COMPONENT III ORIENTATION: A Component III Orientation was conducted with the Administrator during today's visit.



The following needs to be completed/Photos sent to LPA prior to licensure:

 No deficiencies noted.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. A copy of the Licensing Report was issued.
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC809 (FAS) - (06/04)
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