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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850382
Report Date: 04/16/2025
Date Signed: 04/16/2025 04:05:30 PM

Document Has Been Signed on 04/16/2025 04:05 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:MISSION LAND LLCFACILITY NUMBER:
405850382
ADMINISTRATOR/
DIRECTOR:		WON, YOUNGFACILITY TYPE:
735
ADDRESS:1522 N STTELEPHONE:
(805) 610-3676
CITY:SAN MIGUELSTATE: CAZIP CODE:
93451
CAPACITY: 4CENSUS: 2DATE:
04/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Backup Administrator - Junsik KimTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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At 8:00am on 04/16/2024, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the facilities first post-licensing annual facility inspection. LPA met with Backup Administrator, Junsik Kim, announced who he is and the reason for the visit.

Backup Administrator and LPA conducted a full tour of the facility. This facility is a 2-story, 7-bedroom, 3-bathroom home. The first floor has 4 single occupancy client bedrooms, a full bathroom for clients to share, a common area that includes a kitchenette (refrigerator, microwave and sink). The second floor contains 3 live-in staff bedrooms, a common area with full kitchen, dining table, and couch. LPA noted that the backyard has seating and shade for clients. LPA noted facility has battery operated smoke detectors in each room that are all working and a carbon monoxide detector in the common area on each floor functioning normally. LPA observed a fire extinguisher on each floor each tagged current and in the green compression range, serviced on 04/02/2025. LPA noted fresh fruit and snacks in the kitchen for clients to enjoy freely. LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted that the facility is clean and in good repair with no obstructions in hallways, doorways or exits. Medications are locked in a cabinet on the first floor next to the main entry. LPA conducted a medication audit and reviewed the facilities Centrally Stored Medication Records. LPA conducted a staff and resident file review. During the facility tour LPA noted that a client currently resides in designated staff room 1 on the second floor next to the kitchen, violating the fire clearance and facility license.

(Continued 809-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2025
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 8
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MISSION LAND LLC
FACILITY NUMBER: 405850382
VISIT DATE: 04/16/2025
NARRATIVE
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LPA noted 4 of 5 fire sprinkler heads on the ground/first floor of the facility have been painted over. At 11:50am LPA tested facility hot water at the client bathroom sink on the first floor to be 138.5*(f), not within regulation temperatures of 105*-120*(f).

LPA and backup Administrator conducted a review of the annual care tool modules.

Exit interview, deficiencies cited on 809-D pages, civil penalty issued, report given, and appeal rights given.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 04/16/2025 04:05 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 04/16/2025 at 03:03 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MISSION LAND LLC
FACILITY NUMBER: 405850382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA noted 4 of 5 fire sprinkler heads on the ground/first floor of the facility are panted over which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Backup Administrator will contact a fire sprinkler service company by 04/17/2025 and schedule them to come out to assess the fire sprinkler heads for repair. Backup Administrator will email LPA the company and date of schduled inspection.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when at 11:50am LPA measured water temperature at 138.5*(F) at the faucet in the client bathroom on the ground/first floor which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Backup Administrator turned the water temp down on the hot water heater during LPA visit. Backup Administrator will ensure the hot water temperature will be within regulation range of 105-120*(f) and email LPA video of thermometer showing in range.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 04/16/2025 04:05 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 04/16/2025 at 03:03 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MISSION LAND LLC
FACILITY NUMBER: 405850382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by allowing a client to reside in staff designated room 1 on the second floor of the facility violating both the fire clearance and facility license stating "no resident shall reside on the 2ND floor" which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Licensee will ensure that client is moved to the first floor by 04/17/2025. Backup Administrator will email LPA photos of the clients personal belongings in a room on the first floor by 04/17/2025. The process of moving the client started while LPA was still at the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2025


LIC809 (FAS) - (06/04)
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