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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608905
Report Date: 06/19/2026
Date Signed: 06/19/2026 11:28:21 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2025 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20250613145222
FACILITY NAME:MY HOME IIFACILITY NUMBER:
197608905
ADMINISTRATOR:MARK YULEFACILITY TYPE:
740
ADDRESS:6753 ESTEPA DRIVETELEPHONE:
(661) 219-4906
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY:6CENSUS: 6DATE:
06/19/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Josephine Pataueg - StaffTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not prevent resident from developing a pressure injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent complaint visit to this facility to deliver the findings for the above allegations. LPA met with Administrator Mark Yule and explained the reason for the visit.

On 06/13/25, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. On 06/16/25 at 4:40 PM, the department initiated the complaint visit. On 09/12/25, the department conducted interviews with staff, residents, and witnesses on different dates and times from 07/09/25, 07/24/25, 09/09/25, 09/11/25, and 10/14/25, obtained copies of of the facility records relevant to the investigation, and obtained and reviewed hospital records on 07/11/25.

Regarding the allegation: Staff did not prevent resident from developing a pressure injury, it was alleged that Resident #1 (R1) has a Stage IV pressure injury and blanchable redness on R1’s heel.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20250613145222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MY HOME II
FACILITY NUMBER: 197608905
VISIT DATE: 06/19/2026
NARRATIVE
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(continued from LIC 9099)

A record review revealed that R1 was admitted to the facility on 03/15/25. On 04/11/25 R1 was brought to the hospital clinic and was diagnosed with a Stage 2 or 3 pressure wound and was eventually referred to and was admitted for home health services for wound care. On 04/29/25, due to wound improvement, the Home Health services terminated. On 06/04/25 however, care staff from the facility called the hospital due to R1’s decline and wound at the sacral region. Care staff was advised to call 911 but called R1’s family member and R1 was brought to the Hospital’s Emergency Room where R1 was diagnosed with Stage IV pressure wound. On 06/14/25, R1 was discharged to a Skilled Nursing Facility (SNF) for pressure wound, further treatment, and recovery.

Based on the information gathered during the course of the investigation, the allegation is deemed substantiated at this time.

Citation issued, appeal rights explained and given.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250613145222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MY HOME II
FACILITY NUMBER: 197608905
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2026
Section Cited
HSC
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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The Administrator agreed to conduct an in service to all the staff to avoid future occurence of the same inaction and will submit to CCL on or before the POC date.
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This requirement is not met as evidenced by: Based on interview and records review, licensee failed to ensure that the resident was immediately sent for medical attention when observed to be so, this poses an immediate health and safery risk to the residents in care.
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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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3