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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610022
Report Date: 03/13/2025
Date Signed: 03/13/2025 12:31:24 PM

Document Has Been Signed on 03/13/2025 12:31 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:APPLETON HOMESFACILITY NUMBER:
567610022
ADMINISTRATOR/
DIRECTOR:		OLIVAS, MYLINEFACILITY TYPE:
740
ADDRESS:1149 APPLETON RDTELEPHONE:
(747) 237-0417
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 4DATE:
03/13/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:24 AM
MET WITH:Myline OlivasTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced case management – deficiencies visit at the facility at 09:56 AM. LPA met with facility staff who contacted the Administrator Myline Olivas the reason for the visit was explained and entrance interview was conducted. The Administrator arrived to the facility at 11:05 AM.

During the physical plant tour at 10:02 AM LPA observed the back patio of the facility. LPA observed the back patio to contain multiple unsecured tools. LPA observed a hand saw, a crowbar, a circular saw, a box cutter, and other various tools. LPA informed the facility Administrator of the unsecured items. The Administrator stated that a contractor is working to update the kitchen of the facility. The Administrator spoke with the contractor and asked them to secure the tools. The contractor arrived to the facility shortly after and secured the tools at the time of the visit.

Pursuant to Title 22 regulations and/or the Health and Safety Code the following deficiency was cited (refer to LIC 809D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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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Document Has Been Signed on 03/13/2025 12:31 PM - It Cannot Be Edited


Created By: Trevor Byrne On 03/13/2025 at 11:34 AM
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: APPLETON HOMES
FACILITY NUMBER: 567610022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2025
Section Cited
CCR
87309(a)

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87309 Storage Space and Access
(a)... the licensee shall ensure that ... knives...tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended...
This requirement is not met as evidenced by:
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Licensee secured the tools at the time of the visit. POC cleared.
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Based on observation and interview the licensee did not comply with the section cited above as multiple tools were left unattended on the facility's back patio which poses an immediate safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


LIC809 (FAS) - (06/04)
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