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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801259
Report Date: 07/07/2026
Date Signed: 07/07/2026 01:20:03 PM

Document Has Been Signed on 07/07/2026 01:20 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MG2 FAMILY HOMEFACILITY NUMBER:
565801259
ADMINISTRATOR/
DIRECTOR:		MARIA MIRANDAFACILITY TYPE:
735
ADDRESS:5031 HALSEY WAYTELEPHONE:
(805) 488-6527
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
07/07/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:47 AM
MET WITH:Maria MirandaTIME VISIT/
INSPECTION COMPLETED:
01:24 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit. At 11:47AM, the LPA arrived at the facility and met with facility designee Jose Ong. Administrator arrived during the visit. Entrance interview conducted.

Beginning at 11:51AM, the LPA, along with the facility designee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguishers were fully charged and last serviced on 01/07/2026. All smoke and carbon monoxide detectors were tested at 12:58PM and all were functional at time of visit. No fire clearance concerns observed. The facility is vendored by Tri-Counties Regional Center as a level 5 home.

BEDROOMS: There are four (4) total bedrooms in the facility; one (1) is designated as a staff room and was observed to be locked. There are three (3) shared client bedrooms which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are two (2) restrooms which are shared between clients, staff, and visitors. Restrooms were clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Hot water temperature measured at 108.1 degrees Fahrenheit, which is within the required range.

COMMON AREAS: This includes the living room, TV room, and dining area. LPA observed common areas to be clean and properly furnished at the time of the visit. LPA observed required postings in the entrance hallway. There were no obstructions and/or tripping hazards throughout the facility.

Report Continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2026
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MG2 FAMILY HOME
FACILITY NUMBER: 565801259
VISIT DATE: 07/07/2026
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OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for client use. All passageways were observed to be clear. There were no bodies of water on the premises.

GARAGE/LAUNDRY: LPA toured the attached garage by the TV room which is kept unlocked. The garage contained a washer/dryer, emergency food and water supply, additional food and supplies, and locked cleaning solutions and detergents.

KITCHEN: Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility had a sufficient supply of perishable and non-perishable food. Sharp objects and cleaning supplies were stored in a locked and inaccessible in a drawer and cabinet under the sink.

RECORD REVIEW: Beginning at 12:04PM (clients) and 12:41 (staff), LPA reviewed five (5) out of six (6) client files and five (5) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, P&I, health screening, staff training, first aid certification, and fingerprint clearance. All client and personnel files were in order.

MEDICATION REVIEW: Beginning at 12:27PM, LPA reviewed medications for two (2) of six (6) clients. Medications were centrally stored and locked inaccessible in a cabinet by the dining area. All medications reviewed were properly documented on the centrally stored medications and destruction record and no deficiencies were observed during medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, LPA reviewed the facility's infection control policy and emergency disaster plan. Emergency disaster plan is updated annually as required and emergency disaster drills are conducted monthly, with the last drill conducted on 06/10/2026. All documents reviewed were updated and in compliance.

No citations issued. Exit interview conducted. A copy of today's report was provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC809 (FAS) - (06/04)
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