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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850644
Report Date: 10/09/2025
Date Signed: 10/10/2025 07:20:44 AM

Document Has Been Signed on 10/10/2025 07:20 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:INFINITY CARE HOME 2FACILITY NUMBER:
565850644
ADMINISTRATOR/
DIRECTOR:		DE GUZMAN, HAROLD STEVESFACILITY TYPE:
740
ADDRESS:961 FAIRCHILD AVETELEPHONE:
(805) 415-5316
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 0DATE:
10/09/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Harold Steves De GuzmanTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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At 9:30 A.M. Licensing Program Analyst (LPA) Valeria Conway conducted an announced Pre-Licensing Inspection of the above-listed facility. Upon arrival LPA met with Administrator, Harold De Guzman and Back-up Administrator Jocelyn Manacap. Entrance interview conducted.

An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 10/30/2024. A Fire Clearance was approved for a maximum capacity of six (6), five (5) non-ambulatory residents and one (1) bedridden resident. This facility will be housing residents with dementia. A hospice waiver for two (2) was received. The proposed physical plant is a one (1) story single family dwelling located in a residential neighborhood of Camarillo, CA. There are no residents residing in the facility at the moment.

LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service.

Fire extinguishers are fully charged and recently purchased on 06/30/2025. Fire alarms and separate carbon monoxide detectors were tested at 9:50 A.M. and were functional at the time of the visit. LPA observed all required postings on the facility wall. The Emergency and Disaster Plan will be updated before the first resident is admitted.

Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: INFINITY CARE HOME 2
FACILITY NUMBER: 565850644
VISIT DATE: 10/09/2025
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Continued from LIC 809

At 10:00 A.M. a tour of the physical plant was conducted and the following observed:

BEDROOMS: The facility consists of a total of four (4) bedrooms. Rooms #1 through #3 are designated as shared resident rooms, and Room #4 is for staff use only. Additionally, Room #1 is equipped with a fire-rated door that will remain closed and is the only room approved to accommodate a bedridden resident. Room #1 also has a direct exit to the outside, equipped with a self-locking and self-latching gate. All bedrooms were 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. Inside Room #4, the LPA observed the washer and dryer.

BATHROOMS: There are two (2) bathrooms in the house. One is a shared bathroom located in the main hallway for residents, visitors and staff use and another located inside the masted bedroom (Room #1). LPA observed toilets and handwashing stations to be in operation condition. Solid waste containers are in good repair. Hygiene items of general use such as soap, paper towels and toilet paper were observed in each bathroom. Facility provides each resident privacy and personal accommodation. Additionally, bathrooms had slip-resistant mats, and grab bars. Water temperatures were measured in both bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit.



KITCHEN: Appliances and fixtures appeared clean and functional. At the time of the visit, LPA observed a sufficient amount of dining and cookware, non-perishable and perishable food to accommodate a maximum capacity of six (6) residents and facility staff for seven (7) days. Cleaning supplies and chemicals will be stored in locked cabinets located under the sink. Sharps and knives were observed secured in a locked kitchen drawer positioned to the left of the refrigerator. There were no visible immediate hazards observed.

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

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
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: INFINITY CARE HOME 2
FACILITY NUMBER: 565850644
VISIT DATE: 10/09/2025
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Continued from LIC 809-C

COMMON AREAS: These include the Family Room, Living Room and Dining Room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility has a fireplace in the living room. LPA observed the fireplace to be properly screened. There is a designated telephone available and internet service for residents’ 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 the main hallway and passages to nonprivate bathrooms. Facility has an auditory signal system in place at the time of the visit. Facility is equipped with two fire-rated doors, one separating all resident rooms from the common areas and another one located in Room #1. These doors are used to enhance safety and prevent the spread of fire. Per the administrator, these doors will be kept closed during business hours.

MEDICATION: Medications and complete first aid kit will be stored in a locked closet in the hallway across from Room #3. At the time of the visit LPA observed six (6) individual empty plastic containers where medication will be stored for each resident. Facility will properly document medication on the Centrally Store Medication and Destruction log.

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. Gate was observed to be self-closing and latching. There are no bodies of water on the premises during today’s visit. LPA observed sufficient space to accommodate both indoor activities and outdoor activities for residents. All outdoor and indoor passageways were observed free of obstruction.



Continued on LIC 809-C

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

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
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: INFINITY CARE HOME 2
FACILITY NUMBER: 565850644
VISIT DATE: 10/09/2025
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Continued from LIC 809-C

GARAGE: LPA also observed the locked garage, which contains an office equipped with a computer and where all residents’ and staff members’ files will be securely stored to ensure privacy and confidentiality. Furthermore, emergency disaster supplies, locked chemical storage and a sufficient amount of emergency water and emergency food was observed at the time of the visit.


COMPONENT III ORIENTATION: A Component III Orientation was conducted with Administrator and Back-up administrator during today's visit.

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

 No corrections at this time.

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: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC809 (FAS) - (06/04)
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