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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850693
Report Date: 02/05/2026
Date Signed: 02/06/2026 11:43:23 AM

Document Has Been Signed on 02/06/2026 11:43 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:VERNA'S CARE HOMEFACILITY NUMBER:
565850693
ADMINISTRATOR/
DIRECTOR:		STEVENS, EVELYNFACILITY TYPE:
740
ADDRESS:1347 SKEEL DR.TELEPHONE:
(209) 531-8419
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 0DATE:
02/05/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Evelyn StevensTIME VISIT/
INSPECTION COMPLETED:
03:15 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 Licensee, Evelyn Stevens. Entrance interview conducted.

An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 09/26/2025. A Fire Clearance was approved on 12/17/2025, for a total of six (6) non-ambulatory residents only. The proposed physical plant is a one (1) story single family dwelling located in a residential neighborhood of Camarillo, CA. This facility will be housing residents with dementia. This pending facility has a dementia care program and a hospice care waiver for two (2) residents. There are currently no residents being served at the facility. This facility doesn’t have a staff room; facility will provide 24/7 care. At 10:05 A.M. tour of the physical plant was conducted. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following observed:

Bedrooms: The facility has two (2) single bedrooms and two (2) shared bedrooms designated for residents use only. There was a model furnished bedroom equipped and supplied with appropriate furniture including but not limited to a bed, a chair, a nightstand, 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.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2026
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VERNA'S CARE HOME
FACILITY NUMBER: 565850693
VISIT DATE: 02/05/2026
NARRATIVE
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Continued from 809-C

Bathrooms: There are five (5) bathrooms. Each bedroom has its own bathroom and there is one (1) shared bathroom for visitors and staff. LPA observed grab bars for each toilet, and shower used by residents. All bathrooms were supplied with appropriate paper and hygiene products. Water temperatures were measured in all residents’ bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit.

Common Areas: These include the Family Room and Dining Room. The common areas were furnished to accommodate a maximum capacity of six (6) residents. Floor surfaces were clean and in good repair. There were no immediate hazards observed. Fire extinguisher was observed fully charged and last purchased on 02/04/2026. Between 10:21 A.M. and 10:24 A.M., hardwired smoke detectors and a separate carbon monoxide detector were tested and were functional at the time of the visit. The facility does not have a fireplace. Cameras are installed in common areas; according to the licensee, the cameras do not record audio. The LPA observed nightlights installed in all hallways and passageways. The facility has an operational auditory alarm system and is equipped with a fire door to enhance safety and prevent the spread of fire. LPA did not observe the required Personal Rights poster, Ombudsman poster, and the Community Care Licensing (CCL) information poster outlining the complaint process. Office Room: LPA observed a desk and file cabinets. Staff and resident files will be stored in this room and maintained in a locked manner to ensure confidentiality.

Kitchen: Appliances and fixtures appeared clean and functional. There was sufficient dining and cookware to accommodate a maximum capacity of six (6) residents. Facility doesn’t have many perishable items nor fresh fruit because there are no residents at the time of the visit. Knives and other sharps will be stored in a locked drawer next to the dishwasher. Cleaning supplies, soaps and detergents are locked under-sink cabinets and shall be stored in areas separated from food supplies. There were no visible immediate hazards observed. Community phone and internet access is provided by the licensee to the residents.


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

DATE: 02/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026
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: VERNA'S CARE HOME
FACILITY NUMBER: 565850693
VISIT DATE: 02/05/2026
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Continued on LIC 809-C

Garage/Laundry Area: Inside the garage, the LPA observed a washer and a dryer machine. Staff will assist residents with all laundry needs. Additionally, LPA observed an ample supply of emergency water and dried emergency food at the time of the visit.

Surrounding Grounds: Garden and yard are easily accessible to residents, and they are sufficient in size, comfortable and appropriately equipped for outdoor use. Backyard: There was a shaded area with proper furniture for outdoor use. LPA observed one (1) self-closing and latching side gate. There is a locked shed in the backyard that holds gardening tools and extra supplies. LPA observed several gardening beds located in the backyard. LPA advised the licensee that if the gardening beds are used to grow vegetables, the produce shall not be served or provided to residents in care.

Medical Area: Medications are stored in a locked kitchen pantry. There is a complete first aid kit inside a kitchen cabinet. Facility will properly document medication on the Centrally Store Medication and Destruction log (LIC 622) once facility receives first resident.

Infection Control/Emergency Disaster Planning: The LPA reviewed the facility's infection control plan and the emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate.

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

DATE: 02/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026
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: VERNA'S CARE HOME
FACILITY NUMBER: 565850693
VISIT DATE: 02/05/2026
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Continued on LIC 809-C

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

The following needs to be completed/Photos sent to LPA prior to licensure:
 Missing curtains in resident’s rooms and living room.
 Missing posters

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: 02/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026
LIC809 (FAS) - (06/04)
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