565801431-1-29-2025-29-AS-VCOY-DDDKVW-20250129071500

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801431
Report Date: 01/28/2025
Date Signed: 01/29/2025 07:15:09 AM

Document Has Been Signed on 01/29/2025 07:15 AM - 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:	ADVANCED CARE HOME		FACILITY NUMBER:	565801431
ADMINISTRATOR/ DIRECTOR:	KAYHAN MOJABI		FACILITY TYPE:	740
ADDRESS:	144 LA CRESENTA DR		TELEPHONE:	(805) 389-1907
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	01/28/2025
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Kayhan Mojabi		TIME VISIT/ INSPECTION COMPLETED:	12:00 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 case management visit to confirm that the facility is no longer operating as an Residential Care Facility for the Elderly (RCFE) at this location. LPA met with Administrator, Kayhan Mojabi, and explained the reason for the visit. Entrance interview. During today’s visit the LPA conducted a physical plant tour of the facility with the administrator. The LPA observed that care and services are not being provided at this location. According to the administrator, a family member has moved into the home as their personal residence around October 2024. Additionally, on 11/25/2024, the administrator’s family member mailed a certification of non-operation along with facility license to Sacramento. On 01/27/2025, LPA requested formal written confirmation via email of the administrator’s intention to close facility named above. A record review of the facility file revealed that on 08/26/2024 and on 01/22/2025 LPA Conway contacted the administrator via email and telephone regarding unpaid annual fees. During the January communication, the administrator informed the LPA that the facility has been vacant since April 2024, and all residents were safely relocated to a different boarding care facility. The administrator stated the facility was undergoing a change of ownership on or around April 2023. However, Centralized Applications Bureau (CAB) indicated that no change of ownership application been received for the property. Additionally, on January 2024, Community Care Licensing (CCL) conducted a required annual inspection under original administrator. As of today, CCL has not received fees due despite LPA’s efforts to address the matter. Continued on LIC 809-C

Desaree Perera	TELEPHONE: (818) 596-4347
Valeria Conway	TELEPHONE: (818) 454-0485
	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

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

FACILITY NAME: ADVANCED CARE HOME	FACILITY NUMBER: 565801431
	VISIT DATE: 01/28/2025

NARRATIVE

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Continued from LIC 809

The LPA verified that the facility does not have residents living there and that all residents have been safely relocated. Based on the LPA’s observations and information provided the facility has ceased operation and will be officially closed.

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, a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/29/2025 07:15 AM - It Cannot Be Edited

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: ADVANCED CARE HOME	FACILITY NUMBER: 565801431
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.185(a)(1)

Fees for license or applications; use of revenues; collected; denial or forfeiture. After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 02/11/2025
	Plan of Correction
1 2 3 4	Licensee will need to submit payment of Annual fees immediately and notify the LPA once it has been completed.

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	TELEPHONE: (818) 596-4347
Valeria Conway	TELEPHONE: (818) 454-0485
	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

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