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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850606
Report Date: 03/18/2026
Date Signed: 03/18/2026 12:20:38 PM

Document Has Been Signed on 03/18/2026 12:20 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:PROVIDENCE ADULT RESIDENTIAL HOME, INC.FACILITY NUMBER:
425850606
ADMINISTRATOR/
DIRECTOR:		JEMERSON, ANALIZAFACILITY TYPE:
735
ADDRESS:1439 WALLIS AVENUETELEPHONE:
(805) 631-5163
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 4CENSUS: 4DATE:
03/18/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:04 AM
MET WITH:Analiza JemersonTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Rankin arrived at 9:04 a.m. to conduct a 1-year required annual visit. LPA met with Analiza Jemerson, Administrator.

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 a 5 bedroom, two bathroom house with 1 bedroom and 1 bathroom being used by staff. Facility currently occupies 4 clients. LPA toured client rooms and observed that rooms were tidy, the lighting and lamps are sufficient for the use of the facility and for client comfort and safety. Toilet, hand washing and bathing facilities are operational. The showers have non-skid mats. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The facility has telephone and internet service for client use. The fire extinguisher was last charged and inspected on 11/10/25. The facility has carbon monoxide and smoke detectors which were tested during the visit and working. Hot water temperature was measured at within regulation temperatures 105-120*(f). Cleaning supplies are inaccessible to clients in care, kept locked in the garage and under the kitchen sink.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2026
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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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: PROVIDENCE ADULT RESIDENTIAL HOME, INC.
FACILITY NUMBER: 425850606
VISIT DATE: 03/18/2026
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Operational Requirements: The facility has a current plan of operation 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. The fire clearance is granted for 2 non-ambulatory and 2 ambulatory.

Staffing and Personnel Training: The facility currently employs 8 staff, 2 of which are administrator. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, and Health screening with TB results. Training has been done for the 2025 year. Administrator certificate expires 09/02/2027.

Client Records & Incident Reports: The facility keeps separate files on each client confidentially. Facility does submit incident reports to the department when required. LPA reviewed 4 client files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians reports, Pre-appraisals, IPPs, Emergency and ID forms. All forms were legible and complete.

Food Service: The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. Kitchen area and appliances are clean and maintained. Snacks are available when clients want them.

Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR) and Medication Administration Records (MAR). LPA reviewed sampling of clients’ medications, no medications were expired, all records were to update and complete and all medications were kept in their original containers.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts monthly disaster drills; last one conducted on 1/7/26. 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.

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

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC809 (FAS) - (06/04)
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