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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603228
Report Date: 03/28/2026
Date Signed: 03/28/2026 02:37:53 PM

Document Has Been Signed on 03/28/2026 02:37 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:ANTELOPE VALLEY FOUNDATION, INC.FACILITY NUMBER:
197603228
ADMINISTRATOR/
DIRECTOR:		DAVENPORT, GAMZEFACILITY TYPE:
735
ADDRESS:36448 RODEO STREETTELEPHONE:
(661) 533-0974
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 6CENSUS: 4DATE:
03/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Gamze Davenport- AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 3/28/2026 at approximately 10:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the Program Manager, Robert Davenport and stated the reason for their visit. The Administrator, Gamze Davenport arrived shortly after to assist with today’s visit.

LPA asked for the census, Staff and Client Roster. LPA conducted a physical plant tour at approximately 11:30 AM and the following was noted:

The facility is a two-story building with six (6) bedrooms and three (3) bathrooms currently occupying four (4) clients. Two (2) client rooms and one (1) bathroom are located downstairs. The remainder of the bedrooms and bathrooms are located upstairs. There is a designated staff room with its own private bathroom. The facility has an approved fire clearance for six (6) ambulatory clients. The facility is vendor through North Los Angeles Regional Center (NLARC) and is being operated at a Level III Adult Residential Home.

Common areas: The living rooms and dining room were observed to be neat, clean and organized. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 71°F. Multiple fire extinguishers were observed to be located near the kitchen entrance and dated 02/03/2026. LPA observed required postings such as See/Say Something, Facility License and Personal Rights to be located throughout the common areas. A fireplace was observed to be covered and inaccessible to clients. A working telephone was observed.

Bedrooms: The clients’ rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. (continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2026
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANTELOPE VALLEY FOUNDATION, INC.
FACILITY NUMBER: 197603228
VISIT DATE: 03/28/2026
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Bathrooms: Bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured within regulations.

Staff Room: LPA observed staff room locked and inaccessible to clients.

Kitchen: The kitchen was observed to be clean and free from pests. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. The kitchen appliances were observed to be working and in proper condition. The knives/sharps were observed to be kept within a locked box inside of a locked storage closet located near the stairs.

Laundry Room: The laundry appliances were observed to be located near the garage. The laundry appliances were observed to be in proper condition. Cleaning supplies and toxins observed locked in a storage closet alongside the stairs and inaccessible to clients.

Garage: The garage can be accessed from inside of the facility and was observed to be located near the laundry room. The garage was observed to be used for storage purposes.

Backyard: The backyard of the facility is equipped with a designated shaded area with outdoor furniture for clients. There is no body of water located at the facility.

Medications: Medications were observed stored in the locked filing cabinet located downstairs. The first-aid kit was observed to be fully equipped.

Smoke detectors and carbon monoxide observed to be working properly and were tested.

Clients/Staff Records: LPA conducted a complete file review of client records. Client records appeared to be complete and updated. Staff records: LPA conducted a complete file review of one (1) staff record. Staff record appeared to be complete and updated.

There was no immediate health and safety hazard observed during the day of inspection. Exit interview was conducted and a copy of this report was provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2026
LIC809 (FAS) - (06/04)
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