565801108-4-7-2026-29-AS-VCOY-DSX7DM-20260407213434

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801108
Report Date: 04/07/2026
Date Signed: 04/07/2026 09:39:34 PM

Document Has Been Signed on 04/07/2026 09:39 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:	SIMI VALLEY RESIDENTIAL CARE VI		FACILITY NUMBER:	565801108
ADMINISTRATOR/ DIRECTOR:	MARIA MENDEZ		FACILITY TYPE:	740
ADDRESS:	1391 MELLOW LANE		TELEPHONE:	(805) 217-5284
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 6		CENSUS: 6	DATE:	04/07/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	MARIA MENDEZ		TIME VISIT/ INSPECTION COMPLETED:	03:15 PM

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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff, Cassidy Schwab, who contacted the Licensee via telephone. Licensee, Maria Mendez, arrived at the facility at 10:24 A.M and the reason for the visit was explained. Administrator, Jennifer Fulgentes, arrived shortly after. LPA and the Licensee 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.

COMMON AREAS: At the time of the visit, the common area furniture's were observed to be in good condition. A sufficient supply of clean linen and towels were observed stored in the hallway cabinets. The facility maintained a temperature of 70 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and serviced 08/14/2025. Activities and board games were observed stored in the main hallway. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings posted throughout the home. During the plant tour, LPA observed a camera in the hallway facing residents’ rooms. According to the Licensee, the device is currently out of service and not operational.

BEDROOMS: LPA observed six (6) resident bedrooms and one (1) staff room. Resident bedrooms were observed furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Staff room was inaccessible to residents in care at this time.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

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: SIMI VALLEY RESIDENTIAL CARE VI	FACILITY NUMBER: 565801108
	VISIT DATE: 04/07/2026

NARRATIVE

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Continued from LIC 809

BATHROOMS: Bathrooms were observed to be clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured between 105 - 120 degrees Fahrenheit.

BACKYARD: The backyard has a covered outdoor area equipped with furniture including tables and chairs for resident use. The LPA observed two (2) self-latching gates with clear passageways clear of obstruction. The LPA observed a locked shed with gardening tools inaccessible to residents in care. No bodies of water were noted at the time of the visit.

GARAGE: There is an attached garage. LPA observed garage to be inaccessible to residents in care. LPA observed an additional fridge and freezer to store extra perishable food. LPA also observed additional non-perishable supplies, canned goods, PPE, extra incontinent supplies, as well as additional furniture and medical equipment for facility use. Laundry area was located in the garage as well along with an office area.

KITCHEN: LPA inspected the kitchen/food service area at approx. 10:55 A.M. Knives and sharp objects are stored inaccessible in a drawer to the left of the stove. No cleaning supplies were observed stored in the kitchen area. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. Dining area was observed to be clean, and furniture appeared to be in good condition. LPA observed facility files and medication properly stored inaccessible in a cabinet next to the dining area.

RECORDS REVIEW: Starting at 11:20 A.M. Six (6) resident and seven (7) personnel records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. LPA observed that Resident #1 (R1) Tuberculosis (TB) test was missing. Although an order for a chest X-Ray was on file, there was no documentation confirming completion of the X-Ray or any TB test result. Additionally, Staff #1’s (S1’s) medical assessment was misplaced. Technical Violation (TV) issued All other records were observed to be in order at this time.

Continued on LI C809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SIMI VALLEY RESIDENTIAL CARE VI	FACILITY NUMBER: 565801108
	VISIT DATE: 04/07/2026

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Continued on LIC 809-C

MEDICATION REVIEW: Medications are centrally stored in a locked cabinet adjacent to the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. At 1:55 P.M., LPA conducted a medication audit. Medications are properly documented on the centrally stored medications and destruction record. Medications appeared to be given as prescribed at the time of the visit.

The LPA obtained the following documents at the time of visit: Personnel Report (LIC500), Resident Roster (LIC9020), last emergency disaster drill, and a copy of the facility’s liability insurance.

Additionally, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. Emergency disaster drills are conducted quarterly, with the last drill conducted on 02/06/2026.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the 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: 04/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/07/2026 09:39 PM - It Cannot Be Edited

Created By: Valeria Conway On 04/07/2026 at 02:30 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: SIMI VALLEY RESIDENTIAL CARE VI	FACILITY NUMBER: 565801108
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87458(c)(1)(A)

Medical Assessment

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. 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 R1 does not have a TB test result on file which poses an immediate health to persons in care.
	POC Due Date: 04/08/2026
	Plan of Correction
1 2 3 4	Licensee agreed to schedule a TB test prior to the POC due date and will submit the results to LPA once they become available.

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: 04/07/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

LIC809 (FAS) - (06/04)

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