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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606493
Report Date: 03/09/2026
Date Signed: 03/09/2026 03:40:17 PM

Document Has Been Signed on 03/09/2026 03:40 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 CARE HOME #2FACILITY NUMBER:
197606493
ADMINISTRATOR/
DIRECTOR:		KATHERINE JOY LARAFACILITY TYPE:
735
ADDRESS:39717 171 ST. E.TELEPHONE:
(661) 264-4214
CITY:PALMDALESTATE: CAZIP CODE:
93591
CAPACITY: 6CENSUS: 5DATE:
03/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Marie BruTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 03/09/2026 at 12:00 pm Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility for an unannounced one (1) year Required visit. LPA was greeted and granted access by Administrator Marie Bru. LPA explained the reason for the visit and an entrance interview was conducted.

A tour of the physical plant was conducted with Administrator at 12:30 pm. The facility has four (4) bedrooms and two (2) bathrooms, one (1) bedroom is designated for staff use. Currently there are five (5) clients occupying three (3) bedrooms. The facility is Fire Cleared for six (6) ambulatory clients. All clients were out in the community.

Infection Control and Emergency Preparedness Plan: LPA reviewed facility Infection Control Plan and Emergency Preparedness Plan to make sure protocols are being reviewed and/or updated. Plans were discussed and updated.

Living and dining: LPA observed the living room to be neat and clean along with the dining room. Dining table has enough space to seat all clients. The facility maintains a comfortable temperature at 71°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 12:55 pm.

Hallway Closet: LPA observed the locked hallway closet containing cleaning supplies, laundry detergent and a supply of PPE. LPA observed the laundry area to be in the hallway. The laundry detergent was safely locked in the closet.

Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2026
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 CARE HOME #2
FACILITY NUMBER: 197606493
VISIT DATE: 03/09/2026
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Kitchen: LPA conducted a tour of the kitchen at 01:00 pm and observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Frozen foods are properly wrapped and stored. There is an extra freezer adjacent to the kitchen that contains additional food. Food storage and preparation areas are clean and inaccessible to pests. There is one (1) fire extinguisher located in the kitchen, one (1) in the hallway and one (1) near the pantry. The fire extinguishers were observed to be full and last serviced on 04/16/2025. The pantry contained a locked file cabinet which contained client medications. LPA observed there were no knives in the kitchen, they are locked in the staff room. LPA confirmed the staff room was locked but LPA was allowed entry to the room and observed knives locked in a drawer.

Bathrooms: LPA observed both bathrooms which contained wash your hands sign, hand soap, paper towels, and trash cans with lids. Hot water was tested at 01:20 pm in the client bathroom at 117.2˚F.

Client Rooms: LPA observed rooms to have the appropriate bedding. There are nightstands, chairs, dressers and sufficient lighting for each client.



Physical environment: LPA toured the outside area of the facility at 01:40 pm. LPA observed appropriate outdoor furniture, with a shaded area for residents. No bodies of water on the premises.

Administrative: LIC500, Bond and client roster were emailed to LPA. Annual fees are current.

Client and Staff Files: LPA conducted a file review of client and staff records at 2:00 pm.

Medications: At 03:00 pm LPA and Administrator reviewed medication and medication records, no issues noted.

Client and Staff Interviews: LPA was not able to interview clients as they are in day program. LPA was able to interview one (1) staff member that was in the facility.

No citations issued. Exit interview conducted and a copy of the report was provided to Licensee.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
LIC809 (FAS) - (06/04)
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