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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567610022
Report Date: 08/08/2025
Date Signed: 08/08/2025 04:43:07 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/24/2025 and conducted by Evaluator Quoc Huynh
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20250224124702
FACILITY NAME:APPLETON HOMESFACILITY NUMBER:
567610022
ADMINISTRATOR:OLIVAS, MYLINEFACILITY TYPE:
740
ADDRESS:1149 APPLETON RDTELEPHONE:
(747) 237-0417
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 5DATE:
08/08/2025
UNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Myline Olivas - LicenseeTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Facility did not issue a proper refund
Paperwork was not completed in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Quoc Huynh conducted a complaint visit to deliver findings for the above allegations. The LPA arrived at 8:57AM and met with Licensee Myline Olivas and explained the reason for the visit. Entrance interview conducted.

On 02/27/2025, LPA Brian Balisi conducted an initial complaint visit. Beginning at 10:00AM, LPA Balisi toured the physical plant, interviewed staff, and reviewed and obtained pertinent documents.

During today’s visit, LPA Huynh conducted a physical plant tour at 9:12AM to ensure there were no health and safety hazards. The following was then determined:

Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 29-AS-20250224124702
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: APPLETON HOMES
FACILITY NUMBER: 567610022
VISIT DATE: 08/08/2025
NARRATIVE
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Allegations: “Facility did not issue a proper refund” and “Paperwork was not completed in a timely manner”

It was reported that the Licensee of Appleton Homes did not issue a refund to Resident #1’s (R1) representative and did not complete the required documents prior to admission. R1 was admitted to the facility on 02/14/2025 and was immediately removed by R1’s representative on 02/15/2025. The facility’s resident Admission Agreement stated “Facility charges $500 non-refundable move-in fee. This fee is to be used to review the client’s needs assessments, to process forms. There is no security deposit” and “Prior to admission, RESIDENT or RESIDENT’S responsible person shall furnish to FACILITY a current physician’s medical report, tuberculosis clearance and participate in an assessment evaluation (pre-admission appraisal).” R1’s representative reported that on 02/14/2025 during the admission, the Licensee provided blank forms and requested the representative to sign the documents. Additionally, the resident’s representative was not provided copies of the documentation signed and the Licensee did not review any forms with the representative. Witness #1 (W1) confirmed that blank documents were provided for signatures, documents were not reviewed or explained by the Licensee, and no communication from the facility was reported prior to 02/14/2025. The Admission Agreement, Telecommunications Device Notification, Consent for Emergency Medical Treatment, Personal Rights, and Release of Client/Resident Medical Information were completed and signed on 02/14/2025. R1’s Preplacement Appraisal, Appraisal/Needs and Services Plan, and Theft and Loss Policy were signed on 02/14/2025 and blank. R1’s Identification and Emergency Information was signed, but not dated, was also incomplete.

Report Continued on LIC 9099-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20250224124702
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: APPLETON HOMES
FACILITY NUMBER: 567610022
VISIT DATE: 08/08/2025
NARRATIVE
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The facility’s Refund Policy stated: “As required by law, if the resident is evicted because of … (5) Upon movement or family decided to send love one at home or any preferred Facility … NO REFUND, and should remove personal belongings immediately.” R1’s representative reported they requested a refund, and the Licensee stated they did not owe the representative any money. Interview with the Licensee revealed the resident’s representative requested a refund and per the admission agreement, they needed to give at least a 30-day notice. The Licensee stated “they showed up the next day and moved (R1) out.” The facility’s Admission Agreement also stated under the Conditions For Termination of Agreement: “This agreement may be terminated by RESIDENT upon thirty (30) days’ written notice to FACILITY.” R1’s representative provided a written and signed notice on 02/15/2025 at 3:05PM, during the removal of R1.

Based on interview and record review, the Licensee did not abide by the policies written in the admission agreement. R1 was not assessed prior to admission, forms were not processed, and a Physician’s Report without TB result was obtained prior to admission. Additionally, documents provided to R1’s representative during the admission on 02/14/2025 for signatures were not reviewed. The preponderance of evidence standard has been met, therefore the allegations are deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies are cited (Refer to LIC9099-D).

Exit interview conducted. A copy of the appeal rights and today’s report was reviewed and provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20250224124702
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: APPLETON HOMES
FACILITY NUMBER: 567610022
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/09/2025
Section Cited
CCR
87507(f)
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(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.

This requirement was not met as evidenced by:
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The Licensee will review their admission agreement and send CCLD a statement of understanding by POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above as the licensee did not obtain required documents and did not conduct a pre-placement appraisal which poses/posed an immediate health, safety, and personal rights risk to residents in care.
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Deficiency Dismissed
Type A
08/09/2025
Section Cited
CCR
87208(a)
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(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so …

This requirement was not met as evidence by:
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The Licensee will issue R1's representative a refund and send CCLD proof by POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above as the licensee did not issue the resident’s representative a refund which poses/posed an immediate health, safety, and personal rights risk to residents 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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/24/2025 and conducted by Evaluator Quoc Huynh
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20250224124702

FACILITY NAME:APPLETON HOMESFACILITY NUMBER:
567610022
ADMINISTRATOR:OLIVAS, MYLINEFACILITY TYPE:
740
ADDRESS:1149 APPLETON RDTELEPHONE:
(747) 237-0417
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 5DATE:
08/08/2025
UNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Myline Olivas - LicenseeTIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
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9
Resident was not provided ample storage space for personal items
INVESTIGATION FINDINGS:
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3
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5
6
7
8
9
10
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13
Licensing Program Analyst (LPA) Quoc Huynh conducted a complaint visit to deliver findings for the above allegations. The LPA arrived at 8:57AM and met with Licensee Myline Olivas and explained the reason for the visit. Entrance interview conducted.

On 02/27/2025, LPA Brian Balisi conducted an initial complaint visit. Beginning at 10:00AM, LPA Balisi toured the physical plant, interviewed staff, and reviewed and obtained pertinent documents.

During today’s visit, LPA Huynh conducted a physical plant tour at 9:12AM to ensure there were no health and safety hazards. The following was then determined:

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20250224124702
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: APPLETON HOMES
FACILITY NUMBER: 567610022
VISIT DATE: 08/08/2025
NARRATIVE
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Allegation: "Resident was not provided ample storage space for personal items"

It was reported that Resident #1 (R1) was not provided ample storage space for their personal items. Title 22 CA Code of Regulation section 87307(a)(3)(B) stated “Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.” Based on LPA Huynh’s observation during the visit, each resident was provided with the listed items with an additional closet space in each bedroom.

Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time.

No deficiency cited related to the allegation. Exit interview conducted. A copy of today’s report was reviewed and provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6