405850037-7-29-2026-29-AS-MRAN-DWFSYH-20260729141736

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850037
Report Date: 07/29/2026
Date Signed: 07/29/2026 02:18:00 PM

Document Has Been Signed on 07/29/2026 02:18 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:	LA LOMA HOME		FACILITY NUMBER:	405850037
ADMINISTRATOR/ DIRECTOR:	MARISA CARDONA		FACILITY TYPE:	735
ADDRESS:	1151 LA LOMA DR		TELEPHONE:	(805) 723-5104
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY: 4		CENSUS: 4	DATE:	07/29/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:55 AM
MET WITH:	Marisa Cardona		TIME VISIT/ INSPECTION COMPLETED:	02:25 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 8:55 am to conduct a 1-year annual visit to the facility above. LPA met Administrator Marisa Cardona and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The facility is 4 bedroom and 3 bathroom currently occupying 4 residents. The facility is clean, safe, and sanitary. The facility has dual smoke and carbon monoxide detectors and were tested and working at time of visit. The lighting and lamps are sufficient for the use of the facility and for client’s comfort. Toilet, hand washing and bathing facilities are operational and secure grab bars are present. The pathways are clear of any obstructions. Disinfectants, cleaning solutions and poisons are in a locked closet off the main hallway, this door self-locks when closed. The facility has sufficient space inside and outside for activities and visiting. The facility has an enclosed backyard for client use with plenty of shade. The facility has telephone and internet service for client use. 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. Personnel Records & Training: The facility employes 12 staff on schedule, or on call and 1 Administrator. LPA reviewed 5 staff files. Updates to staff files was discussed and a copy of the LIC 311C form were provided. Administrator certificate expires 2/17/2027. Continued on 809-C

Kelly Burley
Melisa Rankin
	DATE: 07/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026

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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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: LA LOMA HOME	FACILITY NUMBER: 405850037
	VISIT DATE: 07/29/2026

NARRATIVE

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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.

Clients Records & Incident Reports: Four files were reviewed for updated Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS) are done as Quarterly ISP reports. The Facility does handle cash resources for all 4 clients in care; review of funds was completed. 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 residents want them. Emergency supply of food and water is available. A menu is posted for clients in care. Modified diets prescribed by a physician are followed for those clients in care.

Health Related Services: Facility provides Centrally Stored Medications to all clients in care. Sampling of Clients’ medication was reviewed for expired medication, proper PRN documentation and complete records. Facility provides transportation to medical and dental appointments when needed.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts monthly disaster drills. Two fire extinguishers were charged and last inspected 04/8/2026. A set of keys is available for staff on all shifts to access full facility in an emergency.

Emergency Intervention: All staff reviewed have CPI Non-Violent Crisis Intervention Training Certificates.

Exit interview conducted, and copy of report printed for Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026

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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