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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609649
Report Date: 11/03/2025
Date Signed: 11/03/2025 04:01:03 PM

Document Has Been Signed on 11/03/2025 04:01 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MOM AND DAD HOME CAREFACILITY NUMBER:
567609649
ADMINISTRATOR/
DIRECTOR:		ARLENE MARTINEZFACILITY TYPE:
740
ADDRESS:743 SARA DRTELEPHONE:
(805) 351-9079
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 6DATE:
11/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Arlene MartnezTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with staff and explained the reason for the inspection. When the LPA arrived there were two staff and six residents present. Administrator Arlene Martinez arrived shortly after. The administrator had to leave at approximately 2PM and designated Carestaff Grace Natividad to review and sign the report.
RECORDS: The LPA initiated a record review. Facility records are stored in a locked medication closet. The LPA observed documentation of Infection Control, Disaster prevention, Emergency and Disaster Plan and last Disaster drill (conducted in 07/2025). The LPA obtained Client Roster, and Staff Roster. The LPA reviewed five (5) out of six (6) resident files and five (5) out of eight (8) staff files. The following was observed: Two (2) residents did not have the Consent for Emergency Medical Treatment form LIC627C on file, one (1) resident did not have an annually updated appraisal/needs and service plan on file, and two (2) residents did not have signed personal rights forms on file. Additionally, two staff did not have a criminal record statement on file and one (1) staff did not have any documentation of medication training.

MEDICATIONS: Medications are locked and centrally stored in a closet in the hall. LPA reviewed medications which appear to be given as prescribed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record.

At 2:10 p.m. the LPA toured the physical plant areas inside and outside, with staff to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Report will continue on LIC809-C, 2nd page.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2025
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 4
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: MOM AND DAD HOME CARE
FACILITY NUMBER: 567609649
VISIT DATE: 11/03/2025
NARRATIVE
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KITCHEN: LPA inspected the kitchen. Knives and cleaning supplies are stored inaccessible in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food and food was stored at appropriate temperatures.

BEDROOMS: The four resident bedrooms were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. This facility has a staff/office room adjacent to the kitchen.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detectors and carbon monoxide detector were tested and were operational at the time of the visit. The facility has a fire extinguisher, fully charged and with the last purchased date of 10/23/2025. The LPA observed required postings throughout the common space. No bodies of water noted.

RESTROOM: The facility has one common restroom and one private restroom for residents' use. Restrooms were observed to be clean and sanitary with hand soap and paper towels. The washer and dryer are in the hallway in a locked closet. There is water and additional food located in the garage. Infection control practices were discussed. The facility has a sufficient supply of Personal Protective Equipment (PPE).

INTERVIEWS: The LPA conducted two (2) resident interviews. No concerns were voiced.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/03/2025 04:01 PM - It Cannot Be Edited


Created By: Esther Cortez On 11/03/2025 at 03:34 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: MOM AND DAD HOME CARE
FACILITY NUMBER: 567609649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one staff that did not have annual medication training on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2025
Plan of Correction
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Licensee agrees to have Staff complete the required annual medication training and submit proof by 11/17/25.
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three (3) residents who were missing either a consent form, personal rights form or an updated appraisal/needs and service paln which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2025
Plan of Correction
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Licensee agrees to ensure all files of the three residents are complete and submit proof by 11/17/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2025


LIC809 (FAS) - (06/04)
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