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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606568
Report Date: 05/22/2026
Date Signed: 05/22/2026 05:28:15 PM

Document Has Been Signed on 05/22/2026 05:28 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:PALMDALE CARE FACILITYFACILITY NUMBER:
197606568
ADMINISTRATOR/
DIRECTOR:		VALEREE ZEPEDAFACILITY TYPE:
735
ADDRESS:2810 E. AVENUE R-15TELEPHONE:
(661) 264-0450
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 4CENSUS: 4DATE:
05/22/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Valeree Zepeda - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:37 PM
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Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced annual required visit and was greeted by a staff member. Staff contacted the Administrator, Valeree Zepeda and informed her LPA was at the facility. LPA met with the administrator shortly after and explained the reason for the visit. The facility is licensed for four ambulatory of which two may be non-ambulatory clients.

LPA Rios with the assistance of the Administrator conducted a physical plant tour of and observed the following.

The facility is licensed for a capacity of four (4) clients. The fire clearance is approved for four (4) clients, 2 ambulatory clients in rooms labeled #1, #2, and non-ambulatory clients in rooms #3. Room #3 can be shared. LPA reviewed the approved Fire Safety Inspection (STD 850) dated 04/29/2006 and the facility sketch. LPA observed a discrepancy with the room designations and the facility sketch. The current designation of rooms does not present a health and safety issue because all clients are ambulatory. LPA will reach out to the Fire Inspector and follow up with the facility.

At entry LPA observed the living room, dining table with chairs, a couch and television. In the living room LPA observed required postings on a bulletin board. The dining table sits the capacity of the facility and is in good repair. In the kitchen LPA observed there to be a sufficient supply of two-day perishable and seven-day non-perishable foods in the facility. The facility has an overflow of food stored in a second refrigerator and freezer in the garage. Food storage and preparation areas are clean and inaccessible to pests. The fire extinguisher is located in the kitchen with purchased date 02/18/2026. Sharps were observed locked in a tool box in a kitchen cabinet. (Continue to LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2026
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: PALMDALE CARE FACILITY
FACILITY NUMBER: 197606568
VISIT DATE: 05/22/2026
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In the hallway LPA observed the thermostat covered with a protective cover to prevent the clients from removing it from the wall. The three (3) resident bedrooms are appropriately furnished and have appropriate lighting. The clients' bathroom was appropriately supplied with hand soap, toilet paper. Paper towels are kept in a hallway closet provided to clients when they use the bathroom. The hot water temperature in the bathroom measured 106.7°F, within regulation. Extra towels and linens were readily available in a hallway cabinet. The washer and dryer is in the attached garage. All chemicals and detergents are kept in a hallway closet inaccessible to residents in care. The backyard is fenced in, and LPA observed appropriate outdoor furniture, with covered shaded area for clients. A carbon monoxide in the hallway and the smoke detectors that are hard wired and interconnected located through out the facility were tested at 3:15 PM and observed to be operational.

At approximately 3:40 PM LPA reviewed the facility’s Emergency Disaster Plan (LIC 610D) with facility sketch, emergency drill records, Personnel Report (LIC 500), Surety Bond and client roster. LPA requested that a copy of LIC 610D be emailed to update the Regional Office facility file. Facility last conducted an Earth Quake Drill on 3/16/2026, Emergency Power Outage Drill on 12/10/2025, and Fire Drill on on 9/10/2025. Four (4) out four (4) client records and three (3) staff records were reviewed. Records were complete and in compliance with licensing forms. Medications are centrally stored and were observed locked in a cabinet by the living room. Medications and medication records were reviewed for proper documentation. Centrally Stored Medication Records are pre-filled by pharmacy and facility keeps a Medication Administration Record (MAR).

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit interview conducted. A copy of the report provided to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
LIC809 (FAS) - (06/04)
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