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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607449
Report Date: 08/02/2026
Date Signed: 08/02/2026 05:10:55 PM

Document Has Been Signed on 08/02/2026 05:10 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
Lookup Error,
, CA
FACILITY NAME:CROMWELL HOMEFACILITY NUMBER:
197607449
ADMINISTRATOR/
DIRECTOR:		RENATA GUZAUSKIENEFACILITY TYPE:
740
ADDRESS:29536 CROMWELL AVE.TELEPHONE:
(661) 702-1808
CITY:VAL VERDESTATE: CAZIP CODE:
91384
CAPACITY: 6CENSUS: 4DATE:
08/02/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Zhamila AnarkulovaTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with staff Zhamila Anarkulova. Administrator Renata Guzauskiene notified over the phone. LPA explained the reason for the visit. The facility is licensed for residents age range 60 and over. Approved for 6 non-ambulatory residents. The facility is a single story structure located in a residential neighborhood. It consists of the following: (4) resident bedrooms, (2) residents bathrooms, kitchen, dining room/ living room, laundry area, attached garage which used as a staff room. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. LPA toured the facility. All indoor and outdoor passageways were free of obstruction. The kitchen was inspected. LPA observed all kitchen equipment to be clean and in working condition. LPA observed sufficient supply of perishable and non-perishable foods. Large scissor, knives/sharps observed unlock in kitchen drawers. Smoke / Carbon monoxide detectors were in compliance and operational. There is (1) fire extinguisher located in the kitchen is fully charged. The common areas are clean and were properly furnished. Resident rooms were sanitary and had the required furniture and furnishings. Medications are centrally stored in a locked cabinet in the kitchen. The resident bathrooms are clean and operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested in the residents’ bathrooms and measured at 125.2°F and 126.1°F, which were not within the required range of 105°F to 120°F. Laundry detergent and cleaning solutions in the laundry area were observed unlocked.

Continue 809

Wei Siew Ho
Nune Margaryan
DATE: 08/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2026
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: CROMWELL HOME
FACILITY NUMBER: 197607449
VISIT DATE: 08/02/2026
NARRATIVE
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 During today’s visit, LPA observed that the garage was being used as a staff room. Access to the garage required entering through the resident bedroom. LPA also observed that a bathroom used by staff was accessed through the resident bedroom. Staff personal belongings were observed in the garage area and in the bathroom. The residents bedrooms was being used as a passageway to access areas used by staff, which did not ensure the resident’s privacy and personal accommodations. LPA reviewed four resident files and three staff files. LPA confirmed that staff working at the facility had fingerprint clearances. During the review of resident records, LPA observed that R1’s and R2’s Physician’s Reports were not updated. R1’s Physician’s Report was dated 09/21/2023, and R2’s Physician’s Report was dated 02/10/2025. LPA reviewed clients medications. Medications are documented properly and given as prescribed.

Deficiencies have been noted on LIC 809D under Title 22 Regulations.

Exit interview conducted with Zhamila Anarkulova and a copy of this report and appeal right were provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2026
LIC809 (FAS) - (06/04)
Page: 5 of 6
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)
Page: 2 of 6
Document Has Been Signed on 08/02/2026 05:10 PM - It Cannot Be Edited


Created By: Nune Margaryan On 08/02/2026 at 03:00 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
,
, CA

FACILITY NAME: CROMWELL HOME
FACILITY NUMBER: 197607449

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above. LPA observed that R1's and R2's Physician's Reports are dated 9/21/23 and 2/10/25, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2026
Plan of Correction
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Licensee/ Administrator shall submit copies of updated Physician's Reports for R1 and R2 before POC due date.
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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Nune Margaryan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/02/2026 05:10 PM - It Cannot Be Edited


Created By: Nune Margaryan On 08/02/2026 at 02:59 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
,
, CA

FACILITY NAME: CROMWELL HOME
FACILITY NUMBER: 197607449

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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. The hot water temperature was tested at the residents bathrooms and measured at 125.2 and 126.1.9 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2026
Plan of Correction
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Hot water temperature was adjusted at the time of visit. The hot water temperature retested and it was measured within Title 22 Regulation guidelines. Citation cleared at the time of visit.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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. LPA observed large scissor and knives/sharps accessible to the residents in unlock kitchen drawers, laundry detergent and cleaning solutions in the laundry area accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 08/02/2026
Plan of Correction
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Scissor and knives/sharps, laundry detergent and cleaning solutions were removed and locked immediately. Citation cleared at the time of visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Nune Margaryan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/02/2026 05:10 PM - It Cannot Be Edited


Created By: Nune Margaryan On 08/02/2026 at 04:27 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
,
, CA

FACILITY NAME: CROMWELL HOME
FACILITY NUMBER: 197607449

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(C)
Personal Accommodations and Services. (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C)No bedroom of a resident shall be used as a passageway to another room, bath or toilet.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above.LPA observed that the garage area was being used as a staff room. Access to the garage required entering through a resident bedroom. LPA also observed that a bathroom used by staff was accessed through the resident’s bedroom. Staff personal belongings were observed in the garage area and in the bathroom. The residents bedrooms was being used as a passageway to access areas used by staff, which did not ensure the resident’s privacy and personal accommodations, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2026
Plan of Correction
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The licensee shall discontinue using any resident bedroom as a passageway to access staff areas, including the staff room and bathroom. The licensee shall ensure resident bedrooms are used only for resident accommodations and privacy is maintained. The licensee shall submit a written plan describing how the facility will prevent resident rooms from being used as passageways.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Nune Margaryan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2026


LIC809 (FAS) - (06/04)
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