<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801832
Report Date: 07/24/2025
Date Signed: 07/24/2025 02:33:09 PM

Document Has Been Signed on 07/24/2025 02:33 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:WILCOX'S MESA HOMEFACILITY NUMBER:
405801832
ADMINISTRATOR/
DIRECTOR:		SHANNON MACKENZIEFACILITY TYPE:
735
ADDRESS:711 RIDGE ROADTELEPHONE:
(805) 929-3118
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 4CENSUS: 4DATE:
07/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:11 AM
MET WITH:Teresa BecerraTIME VISIT/
INSPECTION COMPLETED:
02:45 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) Rankin arrived at 9:11 am to conduct a 1-year annual visit to the facility above. LPA met with Back-up Administrator Teresa Becerra and explained the purpose of the visit. When LPA first arrived one resident was being assisted with a shower and another resident was sitting at the dining table doing a puzzle waiting for an upcoming dr appointment visit.

A tour of the inside and outside of the facility was conducted with the Administrator. The following was inspected and noted during the annual visit:

Physical Plant & Environment Safety: The facility has 4 client bedrooms and 1 client bathroom currently occupying 4 clients. The Licensee lives in the facility and has 1 bedroom, and 1 bathroom dedicated for use. The staff have a staffroom and bathroom upstairs on 2nd floor and it is not currently being occupied by any staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect the facility. The facility has smoke and carbon monoxide detectors which were working at time of testing. The lighting and lamps are sufficient for the use of the facility and for the client’s comfort. The shower has non-skid mat. The toilet, hand washing and bathing facilities are operational and secure grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectants, cleaning solutions and poisons are inaccessible to clients in care locked in a closet off living room. The facility has sufficient space inside and outside for activities and visiting. The facility has a large yard and decks for client use with plenty of shade. The facility has telephone and internet service for client use. Continued 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 14
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 14
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: WILCOX'S MESA HOME
FACILITY NUMBER: 405801832
VISIT DATE: 07/24/2025
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
26
27
28
29
30
31
32
Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 4 non-ambulatory, of which 2 may be bedridden.

Staffing, Personnel Records & Training: The facility employes 8 staff and, 1 Back-up Administrator, and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 staff files. Files reviewed had 1st Aid/CPR, Personnel Records/Application on file, 1 out of 5 staff were missing the original Health screening with original TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions were on file. Administrator Certificate expires 03/11/2026. LPA reviewed staff training records, and staff had the current DSP 1 and working on DSP 2. Additional training is scheduled per request of Tri-Counties.

Clients Rights: All required postings were posted in the common area of the facility. Personal rights and Persons with disabilities, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster is posted at entry. Internet is provided to each client, and each client is given privacy.

Clients Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Reports, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. The Facility does handle cash resources for 2 clients in care. LPA audited 2 clients’ funds with ledgers, cash, and receipts. Facility does submit incident reports to the department when required.

Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables to meet the food service requirements. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the clients want them. An emergency supply of food and water is available. Modified diets prescribed by a physician are followed for those clients in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean. Kitchen staff are observed for personal hygiene and food sanitation practices. LPA requested a water temperature log be started.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
Page: 13 of 14
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: WILCOX'S MESA HOME
FACILITY NUMBER: 405801832
VISIT DATE: 07/24/2025
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
26
27
28
29
30
31
32
Health Related Services: Facility provides Centrally Stored Medications to all clients in care. Clients’ medication records for prescriptions had doctors’ orders present. The facility uses the Medication Administration Records (MAR) and Centrally Stored Medication and Destruct Record (CSMDR) for client medications. LPA audited 3 residents’ medication, prescription labels were not altered, medications were stored in original containers, assistant administrator to implement new processes for medication documentation.

Incidental Medical Services: Facility provides transportation to medical and dental appointments when needed. The facility had a 1st Aid Kit present.

Disaster Preparedness: The current emergency disaster forms were posted. The fire extinguisher was charged. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Exit interview conducted and copy of report printed for Back up to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
Page: 14 of 14