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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604820
Report Date: 08/28/2025
Date Signed: 08/28/2025 09:09:35 AM

Document Has Been Signed on 08/28/2025 09:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:NEW WORLD VILLA SOUTHFACILITY NUMBER:
374604820
ADMINISTRATOR/
DIRECTOR:		CHEN, ZAYDENFACILITY TYPE:
740
ADDRESS:14125 TARZANA RDTELEPHONE:
(858) 748-2888
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 5DATE:
08/28/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:15 AM
MET WITH:Staff, Evangeline PingulTIME VISIT/
INSPECTION COMPLETED:
09:15 AM
NARRATIVE
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Licensing Program Managers (LPMs) Robyn Clark and Lizzette Tellez conducted an unannounced case management deficiencies visit. LPMs were met by Staff 1 (S1), Evangeline Pingul, and were granted entry into the facility. The purpose of the visit was discussed with facility staff.

During today's visit, LPMs, along with facility staff, conducted a brief tour of the facility, observed residents in care, and reviewed facility/resident records.

Three residents (R1-R3) did not have information or forms as required including LIC 602 (Physicians Report) or LIC 601 (Emergency Identification and Information). Two residents (R4 and R5) did not have information or forms required for their medical assessment (LIC 602 Physicians report, or similar).

During the visit, LPM Clark inspected facility time sheet records which indicated that five additional staff members (S2-S6) had time sheets indicating that they had recently worked in the facility. A review of Guardian indicated that only three of those staff members (S1-S3) had active Background Clearance associations to the facility. LPM Clark interviewed Staff 7 (S7) regarding the staff members and S7 reported that they had only worked in the facility for a few weeks and had never met S4, S5, or S6.

LPMs conducted a further review of the Guardian Background Clearance System in an attempt to identify the staff members named in the time sheet log. A name search for S4 revealed no results or indications of an active clearance. S5 was discovered with an active clearance however they were associated to a different facility licensed by the Department. [continued on LIC 809(c)].
NAME OF LICENSING PROGRAM MANAGER: Jerry Romero
NAME OF LICENSING PROGRAM ANALYST: Robyn Clark
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2025
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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: NEW WORLD VILLA SOUTH
FACILITY NUMBER: 374604820
VISIT DATE: 08/28/2025
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S6 was associated to the facility on 7/21/2025, however, they were noted as "not hired due to criminal history check." Inspection of facility timesheets indicated that S6 worked in the facility on 7/22/25, 7/23/25, 7/24/25, 7/28/25, 7/29/25, 7/30/25, 7/31/25, and 8/4/2025 despite failing to clear their background check.

Deficiencies were cited on the attached LIC 809(d) and Civil Penalties assessed and noted on the LIC421BG.

An exit interview was conducted with staff Rivera, and a copy of this report along with Licensee/Appeal Rights were provided at the conclusion of the visit. Their signature on this report acknowledges receipt of these reports and licensee rights.
NAME OF LICENSING PROGRAM MANAGER: Jerry Romero
NAME OF LICENSING PROGRAM ANALYST: Robyn Clark
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/28/2025 09:09 AM - It Cannot Be Edited


Created By: Robyn Clark On 08/28/2025 at 07:00 AM
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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NEW WORLD VILLA SOUTH
FACILITY NUMBER: 374604820

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2025
Section Cited
CCR
87355(e)(3)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility (3) Request a transfer of a criminal record clearance... This requirement was not met as evidenced by:
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S5 is not present and will not work in the facility until a clearance transfer has been completed and S5 is associated to the facility. POC cleared during the visit.
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Based on record review, the licensee did not ensure that a criminal record clearance transfer was complete for 1 of 7 staff members (S5) prior to working in the facility, which poses an immediate health, safety and personal rights risk to 5 of 5 residents in care.
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Type A
08/29/2025
Section Cited
CCR87355(e)(2)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review... shall prior to working... in a licensed facility (2) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement was not met as evidenced by:
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S4 and S6 are not present and will not work in the facility until obtaining a criminal record clearance and associated to the facility. POC cleared during the visit.
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Based on record review, the licensee did not ensure that a criminal record clearance was obtained for 2 of 7 staff members (S4 and S6) prior to working in the facility, which poses an immediate health, safety and personal rights risk to 5 of 5 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.
Jerry Romero
NAME OF LICENSING PROGRAM MANAGER:
Robyn Clark
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/28/2025 09:09 AM - It Cannot Be Edited


Created By: Robyn Clark On 08/28/2025 at 07:24 AM
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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NEW WORLD VILLA SOUTH
FACILITY NUMBER: 374604820

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2025
Section Cited
CCR
87506(a)

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by:
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The licensee will ensure that a separate, complete, and current record is available for every resident in care by the POC due date, and verify by submitting a copy of every resident record to CCL by the POC due date.
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Based on record review, resident records were incomplete for 5 Residents (R1-R5), which poses a potential health, safety and personal rights risk for 5 of 5 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.
Jerry Romero
NAME OF LICENSING PROGRAM MANAGER:
Robyn Clark
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
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