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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602540
Report Date: 11/10/2025
Date Signed: 11/10/2025 03:57:39 PM

Document Has Been Signed on 11/10/2025 03:57 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BELLAMAR LANCASTERFACILITY NUMBER:
197602540
ADMINISTRATOR/
DIRECTOR:
ANALILIA ZARZGOZAFACILITY TYPE:
740
ADDRESS:43454 30TH STREET WESTTELEPHONE:
(661) 949-2177
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 68CENSUS: 44DATE:
11/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Analilia Zarzgoza - Buisness Service ManagerTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 11/10/2025, Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced annual required visit. Upon arrival, LPA was greeted by staff and signed in. LPA met with Business Office Director (BOD) Analilia Zarzgoza and explained the purpose of the visit. Executive Director (ED), Kortnie Spitznogle was not available to meet with LPA but would be available by telephone. LPA requested a copy of the current staff schedule and resident roster.

At 9:34 a.m., the physical plant tour of the facility was initiated by LPA Rios. With the assistance of Victor Rameriz the Building Services Director (BSD), LPA conducted a tour of the facility, both inside and out. The Inspection Tool was used for todays visit.

Common areas, including the lobby, dining area, and activity room within the Assisted Living unit, were observed to assess their ability to safely meet the needs of residents. Observations included cleanliness, the functionality of the signal system, and the presence of appropriate locks. An activity calendar was posted near the dining area, and appropriate postings were visible along the hallway leading to resident rooms. In the activity room, LPA observed four (4) residents along with a nail technician. The floors in the activity room had visible crumbs and debris. LPA inquired about housekeeping and three (3) staff members informed LPA that the housekeeper was scheduled to work today but had not come in. According to the ED, a new housekeeper has been hired; however, the onboarding process may take up to a month. In the meantime, other staff members have been assigned to cover housekeeping duties during the current housekeeper’s days off. The ED also stated that today was not the housekeeper’s regularly scheduled day off, however, an email was sent to staff with instructions to complete housekeeping tasks for the resident rooms assigned for the day. (Continue to LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2025
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELLAMAR LANCASTER
FACILITY NUMBER: 197602540
VISIT DATE: 11/10/2025
NARRATIVE
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(Continued from LIC 809) At the reception desk, LPA obtained a copy of the weekly meal menu, which included Breakfast, Lunch, and Dinner from Sunday through Saturday. The kitchen was observed for its ability to safely prepare and serve meals. Food service was reviewed for appropriate quantity and proper storage practices. At approximately 9:43 a.m., while touring the walk-in refrigerator and freezer, LPA observed prepared food items and ingredients that were not properly stored or labeled. Inside the refrigerator, LPA observed two containers and a tray containing various repackaged meats in plastic baggies. According to a cook present, the containers held hamburger patties and pickles. LPA did not observe labels indicating the contents or the date they were stored. In the walk-in freezer, LPA observed single servings of pie placed on plates and covered with plastic wrap, as well as uncovered single-serving ice cream. No labels were observed on any of these items. LPA observed a sufficient amount of two-day perishable and seven-day perishable food. The Culinary Service Director utilizes Sysco for meal planing and food ordering.

Laundry rooms and other storage rooms were observed for linen, tools, toxic cleansers, and general storage. Laundry rooms accessible to residents were clean and no hazards observed. Storage room and laundry room containing chemicals. detergents and cleaning solutions were observed locked.

At approximately 10:33 a.m., the medication room and cart were reviewed for proper storage. The medication room and cart were observed locked. Complete first aid kits are maintained in the medication rooms. LPA observed a box overflowing with medication on the counter. LPA was informed by staff the medication is ready for destruction. Review of medication revealed a liquid medication bottle that according to staff belonged to a resident that passed away December 2024. According to the ED the facility relies on their pharmacy representative to destroy all medications however the representative had not been following through with this arrangement. LPA's review of the Plan of Operation outlines that permanently discontinued medications will not be retained at the facility. Instead, a designated staff member confirms the discontinuation with the physician, discusses it with the resident or responsible party, and ensures proper disposal and documenting the process on the Centrally Stored Medication Record.

LPA toured six (6) randomly selected resident bedrooms, two (2) of which were vacant. Personal accommodations were observed to meet standards for safety, privacy, and comfort. Hot water temperatures in the facility’s bathrooms are logged and maintained by the BSD. During the visit, hot water temperatures were measured and ranged between 105 and 120 degrees Fahrenheit.

(LIC809-C continued) Page 2 of 3

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELLAMAR LANCASTER
FACILITY NUMBER: 197602540
VISIT DATE: 11/10/2025
NARRATIVE
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The front entrance and back patio area of the facility was inspected to insure that passageways were clear of any obstruction. No bodies of water observed.

In the Memory care unit LPA also conducted an inspection of the common areas, resident bedrooms, medication and storage rooms. The memory care unit is equipped with delayed egress doors. One (1) of four (4) delayed doors was tested by LPA and did not open when held past 30 seconds. The door is an emergency exit that leads to a fenced in back patio. According to the Generations Program Director a resident had been constantly pushing the door to open which may have caused the malfunction. LPA observed the medication cart was unlocked and unattended while LPA waited for staff to become available to open the medication room. According to the staff they were actively providing medications which is why the medication cart was unlocked. In bedroom number 15, LPA observed that the kitchen faucet was bent, a drawer in the bathroom was missing, and the toilet paper holder had been removed, leaving a small hole in the wall. According to the BSD, staff who have daily contact with residents are expected to report maintenance issues so they can be addressed in a timely manner. The BSD stated that now that they have personally observed the needed repairs in room 15, they will document the issues and begin repairs as soon as possible.

Facility's fire extinguishers were current and last serviced on 10/02/2025 and located throughout the facility's hallways of the first and second floor. LPA observed flash lights in each fire extinguisher compartment. The facility's smoke alarms are hardwired and interconnected. Carbon monoxide detectors observed in the hallways of both the first and second floors. The last fire inspection was conducted on 03/12/2025 and the facility passed.

Due to time constraints, LPA was unable to finish the inspection and will return another day.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, citations and appeal rights issued. Exit interview conducted, copy of this report given.

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NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 11/10/2025 03:57 PM - It Cannot Be Edited


Created By: Evelin Rios On 11/10/2025 at 02:53 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLAMAR LANCASTER

FACILITY NUMBER: 197602540

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 cart was left unlocked and unattended by staff in the memory care unit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2025
Plan of Correction
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Executive Director agrees to conduct in service training regarding facility's medication policy with staff responsible for medication assistance. A copy of the sing in sheet and training material used will be sent to LPA by POC due date 12/05/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/10/2025 03:57 PM - It Cannot Be Edited


Created By: Evelin Rios On 11/10/2025 at 02:53 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLAMAR LANCASTER

FACILITY NUMBER: 197602540

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87413(a)(1)
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in not adequately identifying staff with qualifications to preform the responsibilities of the housekeeping when the regularly scheduled housekeeper does not show up to work which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2025
Plan of Correction
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Executive Director agrees to adequately identify staff coverage and not include staff not currently working on the personnel report as if they are. Executive Director agreed to provide LPA with the names of staff appropriately qualified to cover housekeeping when the housekeeper is not working by POC 11/28/2025.
Type B
Section Cited
CCR
87555(b)(9)
87555 General Food Service Requirements. b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in having food not properly stored or labeled which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2025
Plan of Correction
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The Executive Director agrees to conduct food safety training for all kitchen staff and provide a copy of the sign-in sheet with training material used to LPA by POC due date 11/28/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/10/2025 03:57 PM - It Cannot Be Edited


Created By: Evelin Rios On 11/10/2025 at 02:58 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLAMAR LANCASTER

FACILITY NUMBER: 197602540

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(i)

87465 Incidental Medical and Dental Care (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and interview, the licensee did not comply with the section cited above in several medications designated for disposal from at least one year ago still kept in the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2025
Plan of Correction
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Executive Director aggress to destroy current medication appropriately and document on Destruction log and send a copy to LPA by POC due date 11/28/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2025


LIC809 (FAS) - (06/04)
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