<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561704034
Report Date: 11/20/2025
Date Signed: 11/20/2025 01:42:44 PM

Document Has Been Signed on 11/20/2025 01:42 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:CAMARILLO HEALTH CARE DISTRICTFACILITY NUMBER:
561704034
ADMINISTRATOR/
DIRECTOR:		MARY ANN RATTOFACILITY TYPE:
775
ADDRESS:3639 EAST LAS POSAS ROAD #117TELEPHONE:
(805) 388-1952
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 40CENSUS: 32DATE:
11/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Amy BukalTIME VISIT/
INSPECTION COMPLETED:
02:00 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) Valeria Conway conducted an unannounced Required Annual inspection at the day program today and met with Program Coordinator, Amy Bukal. LPA informed the reason for the visit. Program Director, Mary-Ann Ratto, was unavailable during today's visit, however, Program Coordinator is authorized to sign today's reports. Entrance interview conducted.

When the LPA arrived, there were nine (9) participants and four (4) staff present. Beginning at 09:15 A.M., the LPA, along with Program Coordinator, toured the physical plant areas to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

The fire safety inspection related to the facility's pull system was last conducted on 04/04/2025 and no violations were observed at that time. Carbon Monoxide Detector was tested at 10:00 A.M. and functioned properly.

Kitchen/Food Service: The food service area was observed. The day program serves lunch and snacks to the participants. Menu is posted. Food was observed to be stored, prepared and served in a safe and healthful manner. Knives are stored in a locked drawer. Cleaning supplies are locked in a cabinet under the sink. The fire extinguisher in the kitchen was fully charged and last serviced on 11/16/2025.

Restrooms: There are three unisex restrooms for participant use. Restrooms were observed to be clean and sanitary and in operating condition with grab bars and hygiene supplies. LPA measured the hot water in participant restroom, which measured within the required range.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2025
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 4
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)
Page: 2 of 4
Document Has Been Signed on 11/20/2025 01:42 PM - It Cannot Be Edited


Created By: Valeria Conway On 11/20/2025 at 12:10 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: CAMARILLO HEALTH CARE DISTRICT
FACILITY NUMBER: 561704034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.2(g)(1-5)
82068.2(g)(1-5) Needs and Services Plan (g) The licensee shall involve the following persons in the development of the Needs and Services Plan: (1) The client and his/her authorized representative, if any…


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the Needs and Services plan did not contain signatures from the participants or their responsible party which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2025
Plan of Correction
1
2
3
4
Director agreed to review each Needs and Services Plan with participant and/or their reponsible party to obtain the required signatures and submit proof to LPA before the POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: CAMARILLO HEALTH CARE DISTRICT
FACILITY NUMBER: 561704034
VISIT DATE: 11/20/2025
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
26
27
28
29
30
31
32
Continued from LIC 809

Common Areas: The facility contains a dining room/activity area, as well as an additional activity area, indoor gardening center and two (2) resting areas for participants if needed. The activity schedule was posted, and supplies were observed. The required postings were observed.

Medications: Medication room was observed to contain a lockbox inside a locked cabinet. Medication records are also stored inside the cabinet. First aid kit was observed to be complete.

Record Review: Staff and participant records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, participant physician's report, needs and service appraisal, and personal rights. LPA reviewed six (6) participants’ files and observed that, although each file contained a Need and Services Plan, the documents were signed only by the Program Director. Per the Program Coordinator, Needs and Services Plans are completed every six months, and while a copy is mailed to the responsible party, there is no procedure in place to confirm that the form has been received and/or reviewed by the participant or responsible party. All seven (7) staff files were in compliance with regulation.

LPA requested the following documents: Personnel Record (LIC 500), Participant roster, current liability insurance, Emergency Disaster Plan and last emergency drill. LPA observed that the last emergency drill was conducted on 10/03/2025 and the Emergency Disaster Plan had not been reviewed or updated for the current year as required by regulation. Technical Advisory (TA) issued.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4