197609060-1-5-2026-31-AS-ERIS-DQ2TTT-20260105140117

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609060
Report Date: 01/05/2026
Date Signed: 01/05/2026 02:02:04 PM

Document Has Been Signed on 01/05/2026 02:02 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:	TREASURE HERITAGE		FACILITY NUMBER:	197609060
ADMINISTRATOR/ DIRECTOR:	OLOWOSAGBA, SUNDAY		FACILITY TYPE:	740
ADDRESS:	2049 KALLIOPE AVENUE		TELEPHONE:	(661) 886-8791
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6		CENSUS: 5	DATE:	01/05/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Sunday Olowosagba - Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

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On 01/05/2026 at 9:30 a.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Required Annual Inspection at this facility. LPA was greeted by caregiver who granted access. LPA explained the reason for the visit. Caregiver sent the administrator, Sunday Olowosagba a message and informed him LPA was at the facility to conduct an annual visit.

A physical plant tour was initiated at approximately 10:00 a.m., and the following was observed:

Entrance: LPA observed required postings at the facility's entrance and a sign in sheet for visitors. LPA observed a fully charged fire extinguisher with service date 05/29/2025.

Common Areas: These include the two (2) dining areas, living area and a sitting/office area. All common areas were observed clean. There is a television and board games available to residents in the living room. Facility files are kept locked in filing cabinets in the dining area.

Kitchen: LPA observed the kitchen to be clean and clear of clutter. LPA observed a fire extinguisher with a service date of 05/29/2025, fully charged. LPA observed, centralized medications locked in a kitchen cabinet. LPA observed a small refrigerator for medication that requires refrigeration locked. LPA observed a 2 day perishable and 7 day non perishable supply of food in the facility.

Surrounding Grounds: There is appropriate outdoor seating for residents. Auditory alarms on exit doors were observed on and functioning.

Laundry Room/Garage: LPA observed a washer, dryer detergents and cleaning products locked in the laundry room. Through the laundry room is the door to the garage. Garage is used for facility storage. LPA observed a second refrigerator. (Continued to LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/05/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026

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: TREASURE HERITAGE	FACILITY NUMBER: 197609060
	VISIT DATE: 01/05/2026

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(Continued from LIC809) Bedrooms: The facility has three (3) bedrooms that may be shared for a total capacity of six (6) residents. Bedrooms are cleared for one (1) bedridden resident each. All resident rooms are furnished with required lighting, dresser, chair, bed, linens, and storage space.

Bathrooms: There are two (2) bathrooms designated for resident use. One (1) bathroom is located in a shared bedroom for private use. All bathrooms were clean, had grab bars, with non skid flooring. LPA observed a sufficient supply of hand soup, toilet paper, and paper towels. Hot water temperature has been measured at approximately, 119 degrees Fahrenheit.

Resident file: At approximately 10:52 a.m. to 12:30 p.m., LPA conducted a file review of five (5) out of five (5) resident records. LPA reviewed resident record to insure compliance of licensing forms. LPA's review of Resident #2's (R2's) records revealed from 09/02/25 to 12/24/25 the facility had documented ongoing behavioral concerns and medical concerns. On one occasion on 08/18/25 R2 left the facility without assistance. LPAs review of Community Care Licensing (CCL) records revealed no unusual incident/injury reports regarding R2 have been submitted by the facility. LPA's review of Resident #3's (R3's) records revealed no TB results on file.

Staff Files / Facility records: At approximately 12:30 p.m. LPA also conducted a file review of two (2) staff records to insure forms and training are up to date and in compliance with licensing forms. At 12:45 p.m., LPA met with the administrator. LPA reviewed infection control plan, liability insurance and emergency disaster plan (LIC610E).

LPA observed smoke detectors through out the facility, they are interconnected and hard wired. LPA observed a functioning carbon monoxide detector on a wall by the bedrooms. At approximately 12:47 p.m. the administrator tested the smoke alarms and they were observed operational. LPA observed fire doors close automatically.

Deficiencies were observed during todays visit (refer to LIC809-D). Exit interview conducted. Appeal Rights provided. A copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/05/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/05/2026 02:02 PM - It Cannot Be Edited

Created By: Evelin Rios On 01/05/2026 at 01:27 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TREASURE HERITAGE	FACILITY NUMBER: 197609060
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87211(a)(1)

Reporting Requirements

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and LPA's interview with the administrator, the licensee did not comply with the section cited above in not reporting within seven days of the occurrence unusual incident/injury regarding R2 to CCL which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/23/2026
	Plan of Correction
1 2 3 4	Administrator agreed to provided Unusual Incident/Injury Reports to LPA for the events involving R2 that occurred in December 2025.

Type B

Section Cited

CCR

87458(c)(1)(A)

Medical Assessment

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 5 resident (R3) did not have TB exam results on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/23/2026
	Plan of Correction
1 2 3 4	Administrator agreed to provide copies of resident's TB results to LPA by POC due date 01/23/26.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:

	Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/05/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026

LIC809 (FAS) - (06/04)

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