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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850042
Report Date: 01/10/2025
Date Signed: 01/10/2025 01:28:21 PM

Document Has Been Signed on 01/10/2025 01:28 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:NANCY'S RESIDENTIAL CAREFACILITY NUMBER:
425850042
ADMINISTRATOR/
DIRECTOR:
SOLORIO, NANCYFACILITY TYPE:
735
ADDRESS:1043 NORTH E PLACETELEPHONE:
(805) 868-5000
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 4CENSUS: 3DATE:
01/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Nancy Solorio, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 01/10/2025, Licensing Program Analyst (LPA) Brian Phillips arrived unannounced for an unscheduled visit to conduct a required Annual Facility site inspection visit at the facility above. When the LPA arrived, they were greeted by Administrator Nancy Solorio, and informed them of the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This is an Adult Residential Facility (ARF), with an approved fire clearance capacity of four (4) residents, of which two (2) may be non-ambulatory. The physical plant of the facility contains four (4) resident bedrooms, and three (3) resident bathrooms, kitchen, dining room, living room, sun room/patio room/game room, and laundry room. There is an outside area on the side and front of the facility for clients to utilize for outdoor activities and an outdoor patio area with furniture and shade.

The LPA inspected the food service area in the facility and observed that items which could constitute a danger to clients are kept inaccessible to clients. All appliances were in operable condition and looked clean/in good repair. Appliances such as microwaves, refrigerators, stoves, etc. are clean and operating properly. Food utensils, dishes, glasses, etc. are clean and in good repair with no cracks or chips. There is enough tableware and utensils for all clients living in the facility, and enough equipment for the storage, preparation, and service of food. LPA observed an appropriate/adequate amount of perishable and non-perishable food items maintained in the facility. Furniture is room/client appropriate, clean and in good repair. All rooms are appropriately furnished for their intended use such as bedrooms, common areas, etc. Hot water temperature is maintained between 105-120 degrees Fahrenheit as per Community Care Licensing (CCL) Title 22 regulations. Outdoor activity spaces have shaded areas and furnished for outdoor use. Each client has an adult bed with a mattress, pad, bedsprings, and pillow, which are clean and in good repair. Each bed is fitted with sheets, pillowcase, blankets, and bedspread that are clean and in good repair. Each client has adequate dresser and closet space for clothing and other belongings that includes at least two drawers or adequate dresser space. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NANCY'S RESIDENTIAL CARE
FACILITY NUMBER: 425850042
VISIT DATE: 01/10/2025
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The facility has a sufficient supply of linens to permit weekly changing or more often to always ensure clean linens for clients. Equipment and supplies for client personal hygiene is available and on site. Activity supplies are available for clients. As the facility has an approved fire clearance for a maximum capacity of four (4) clients, a signal system was not observed by LPA nor required by the Licensing Agency. Refrigerators and freezers are maintained at an appropriate temperature Fahrenheit as per CCL regulations. Food storage and preparation areas are clean and appropriate for food preparation. The food service areas are clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. Cleaning supplies are kept in areas separate from where food supplies are stored. Walls, ceilings, floors, carpeting, window screens, and areas around the facility are clean, painted and/or in good repair. There are locked storage area(s) for poisons, toxic, cleaning solutions, disinfectants, etc. Fire extinguishers and smoke detectors operate properly. Doors and passageways are unobstructed. There are no pools/bodies of water on the physical plant of the facility as observed by LPA. During the inspection, LPA did not observe any firearms that would require trigger locks, locked and inaccessible, or firing pins removed.

The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms in the facility were sufficiently stocked with soap, paper towels, required postings, and clean trashcans with closed lids. Towels and washcloths are not shared by clients in the facility. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per Title 22 regulations between 105-120 degrees Fahrenheit. All toilets and hand washing areas are maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences are available accommodate any physically handicapped clients who need such items. The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Each client bedroom has a bed, nightstands, and lights and nightstand lamps to provide sufficient lighting. Each closet in all the client rooms can store or has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any client. The client bedrooms are big enough for all beds, furniture, and any client assisting device a client might need such as a wheelchair or a walker. Each room has sufficient lighting for each client. The facility has provisioned to each client of furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene.

Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NANCY'S RESIDENTIAL CARE
FACILITY NUMBER: 425850042
VISIT DATE: 01/10/2025
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An emergency exiting plan and emergency phone numbers are posted in an appropriate place. First-aid supplies, which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual, are maintained. Administrator’s records, employees and client records are maintained at the facility and available for review by the LPA as employees are hired and clients accepted into the facility. The facility complies with CCL standards for health screening, TB clearance, staff training, criminal background clearance and transfer requests. Admission agreements and needs and services (ANS) plan are maintained for each client and/or their authorized representative. Client records are maintained on the facility premises in a secured area. Centrally stored medications are locked inaccessible to clients. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. The facility administrator meets the qualifications as specified in Title 22 regulations with a pending renewal ARF administrator certificate application received on 08/12/2024. Provider Information Notices are available and able to be presented to Staff, clients, visitors, and accessible to LPA upon request during the inspection process.

The facility is still in the process of building a Detached Accessory Dwelling Unit (ADU) on the physical plant for a relative of the administrator of the facility. The Administrator has previously provided the LPA during the last facility evaluation visit in 2024 with documentation of a City Permit detailing the project, scope of work, specific dimensions of the construction, and plan of construction. The Permit to build the Detached ADU in the back area of the facility inaccessible to clients was approved by the City on 08/22/2023.

Exit interview conducted by LPA. Copy of this report provided to the facility.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC809 (FAS) - (06/04)
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