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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800528
Report Date: 04/16/2024
Date Signed: 04/16/2024 01:09:16 PM


Document Has Been Signed on 04/16/2024 01:09 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:CAVILLA CARE HOMEFACILITY NUMBER:
425800528
ADMINISTRATOR:JOYCE V. CABANDONGFACILITY TYPE:
740
ADDRESS:1029 RED BARK ROADTELEPHONE:
(805) 928-8617
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 3DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Joseph CabandongTIME COMPLETED:
01:30 PM
NARRATIVE
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 At 8:00 am on 04/16/2024, Licensing Program Analyst (LPA's) Rankin and Jeffries arrived to the facility unannounced to conduct the annual facility inspection. LPA's met with Licensee's Joyce and Joseph Cabandong announced who they are and the reason for the visit.

Licensee and LPA's conducted a full facility physical inspection. LPA's noted that this is a 6 bedroom , 3 bathroom, den, two living room area's, dining room and kitchen. Medications are locked in two cabinets in the kitchen area and staff and residents records are kept in a locked cabinet in the den. LPA's tested smoke detectors and carbon monoxide detectors to all be in working condition. LPA's observed the garage door to be locked however one of the locks required adjustment. LPA's noted that all resident bedrooms had required furnishings and bedding by regulations. LPA's noted that the facilitates water temperature was with in regulations temperature. LPA observed at least two days of perishable and at least 7 days of non-perishable foods on hand for 6 residents and staff. LPA's conducted a staff and resident file review. LPA's conducted a sample medication audit. LPA's noted that Centrally Stored Medication Record (CSMR) was missing and two needed updating, this was addressed in the care tools modules. LPA's noted that the facility was clean and in good repair. LPA noted that all passageways and doors were clear of obstacle and debris. LPA's noted that both fire extinguishers observed were pressurized and in the green reading.

Licensee and LPA's conducted a full review of the annual care tools modules. LPA's note two citations during the care tools module. Administrators certificate was expired. LPA's address expired certificate with Licensee as requiring additional hours for completion and current administrators certificate. The second violation as noted above, CSMR was missing and not updated, this resulted in a citation and required mitigation with in 24 hours. LPA noted that no other citations were issued as a result of this annual facility inspection.
Exit interview, report read, appeal rights provided, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
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 4


Document Has Been Signed on 04/16/2024 01:09 PM - It Cannot Be Edited

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: CAVILLA CARE HOME
FACILITY NUMBER: 425800528

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 04/16/2024 01:09 PM - It Cannot Be Edited

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: CAVILLA CARE HOME
FACILITY NUMBER: 425800528

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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2
3
4
Section Cited
Deficient Practice Statement
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2
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4
POC Due Date:
Plan of Correction
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3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4