197610381-5-16-2026-31-AS-JGTN-DU5QLS-20260516121625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610381
Report Date: 05/16/2026
Date Signed: 05/16/2026 12:17:21 PM

Document Has Been Signed on 05/16/2026 12:17 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	RAYWOOD VILLA INC		FACILITY NUMBER:	197610381
ADMINISTRATOR/ DIRECTOR:	FONSECA, JASON		FACILITY TYPE:	740
ADDRESS:	42659 RAYWOOD DRIVE		TELEPHONE:	(562) 481-6306
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6		CENSUS: 5	DATE:	05/16/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:56 AM
MET WITH:	Ruel Deleon - Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jose Tan conducted an Annual Required visit and inspection of this facility. LPA met the Administrator Ruel Deleon and explained the reason for the visit. The facility is fire cleared for non-ambulatory residents three (3) of which may be bedridden, hospice waiver for six (6) residents. LPA conducted a physical plant tour at 9:17 AM., and observed the following: Kitchen: LPA observed the kitchen to be clean and clear of clutter. Appliances and fixtures were functional. LPA also observed a 7 day supply of non-perishable amount of food and a 2 day supply amount of perishable food in the facility. Cleaning products were observed to be locked in a the laundry room. Bedrooms: LPA observed a total of five (5) bedrooms designated for residents' use. One (01) bedroom may be shared. An additional one (1) bedroom and one (1) bathroom is designated for staff use. Resident bedrooms were observed clean and free of clutter, properly furnished with appropriate beds, night stands and chairs. Doors in bedrooms leading to the outside had auditory alarms that were observed functional. LPA observed night-lights through out the facility. Bathrooms: There are two (2) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 108.3°F. and 117.1°F. Common Areas: These included living room, and the dining area. The common areas were properly furnished. The dining area has a table with chairs to sit the capacity of the facility. The living room has a television with seating that was observed in good repair. LPA observed activities and games for the residents. (continued to LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2026

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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: RAYWOOD VILLA INC	FACILITY NUMBER: 197610381
	VISIT DATE: 05/16/2026

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(continued from LIC 809)

Outside/Surrounding Grounds: LPA observed that the entry/exits were free of obstruction. There is a shaded area for residents to use and furniture appropriate for outdoor use. The backyard has a enclosed patio that offers shade for residents. The patio area is sufficient in space for outdoor exercise and activities. There is a fish pond not in use closed and locked with wood and grate.

Laundry/Garage: The laundry room leads to the attached garage. The door to the laundry room was observed locked. Cleaning supplies and detergents are kept locked in the garage. The garage is used for facility storage.

Smoke detectors/carbon monoxide. All resident rooms are equipped with smoke detectors and the facility's smoke detectors are hard wired and interconnected. The carbon monoxide detector is located in a hallway leading to bedrooms. Detectors were tested by and were observed operational. A fire extinguisher located by the kitchen was observed fully charged and last bought on 05/16/25.

Medications: LPA observed medication in the bedroom hallway cabinet and observed to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. First aids kits have complete tools and supplies.

Client records: Client records are reviewed and appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff record. Staff records appeared to be complete and updated.

Disaster drill was last conducted on 02/17/26. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and copy of this report issued.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2026

LIC809 (FAS) - (06/04)

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