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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801892
Report Date: 12/12/2025
Date Signed: 12/12/2025 01:52:48 PM

Document Has Been Signed on 12/12/2025 01:52 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:FILLMORE COUNTRY CLUBFACILITY NUMBER:
565801892
ADMINISTRATOR/
DIRECTOR:		CONNIE SMILEYFACILITY TYPE:
740
ADDRESS:827 RIVER STREETTELEPHONE:
(805) 524-5080
CITY:FILLMORESTATE: CAZIP CODE:
93015
CAPACITY: 66CENSUS: 27DATE:
12/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Connie SmileyTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Brian Balisi and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at approx 9:00 a.m. Upon arrival, LPAs were greeted by the front desk receptionist and explained the reason for the visit.  LPA's met with Executive Director Connie Smiley shortly after. At approx 09:40 a.m. LPAs along with Executive Director Connie Smiley, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:
LPAs inspected the kitchen/food service area.  Knives are stored and inaccessible to residents. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. A sufficient amount of emergency food was observed properly stored.
The furniture in the common areas were observed to be clean and in good condition. The facility maintained a comfortable temperature. LPAs observed required postings throughout the common space. 
At approx 10:06 a.m LPA's observed that One (1) out of (3) Stairwells did not have an emergency evacuation chair. 
LPA's did not observe any obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. LPAs observed multiple randomly selected  resident bedrooms on the first and second floor. 
All resident bedrooms were furnished appropriately and had sufficient lighting.  All resident restrooms appeared to be clean,  sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels.  The hot water temperature was measured  between 109– 117 degrees Fahrenheit.
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2025
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 5
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: FILLMORE COUNTRY CLUB
FACILITY NUMBER: 565801892
VISIT DATE: 12/12/2025
NARRATIVE
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Continued from 809
The LPAs observed appropriate outdoor furniture, with a covered shaded area for resident use. The facility maintained a comfortable temperature of 73 degrees. LPAs observed cameras throughout the common areas. LPA's requested to review live and recorded footage and observed that the audio components were disabled on each video.  Facility provides sufficient space to accommodate both indoor and outdoor activities.
LPA’s reviewed five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan.  All records were in order at this time. LPA's reviewed Personnel records, five (5) personnel files. File's were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

Medications review . All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file.  Medication appeared to be given as prescribed at the time of the visit.

At approx 12:37 p.m. LPA's observed four (4) residents that had their medications stored in pre-poured cassettes stored for at least (2) weeks. Three (3) out of (4) of these residents did not have prescription orders on file for review.

Infection Control Plan / Emergency Disaster Planning: During today's visit, LPAs reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced 01/21/2025.  Emergency disaster drills conducted quarterly as per regulation; the last fire drill was conducted on 12/06/2025.

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

During today’s visit LPA obtained a copy of the facility’s LIC 500 and resident roster. Exit interview conducted, appeal rights discussed and copy of the report was issued.
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/12/2025 01:52 PM - It Cannot Be Edited


Created By: Brian Balisi On 12/12/2025 at 01:20 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: FILLMORE COUNTRY CLUB
FACILITY NUMBER: 565801892

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review the licensee did not comply with the section cited above as (3) residents did not have a centrally stored medications list on file for review, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2025
Plan of Correction
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Licensee agreed to create a centrally stored medication list for those (3) residents and review section cited then provide LPA with a written plan to ensure future compliance and send to LPA via email by COB 12/15/2025.
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review the licensee did not comply with the section cited above as (4) residents had their medications pre-pored in cassettes, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2025
Plan of Correction
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Licensee agreed to discontinue to prefill medications and review section cited then provide LPA with a written plan to ensure future compliance and send to LPA via email by COB 12/15/2025.
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:
Brian Balisi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/12/2025 01:52 PM - It Cannot Be Edited


Created By: Brian Balisi On 12/12/2025 at 01:20 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: FILLMORE COUNTRY CLUB
FACILITY NUMBER: 565801892

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as one (1) stairwell did not have an emergency evac chair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2025
Plan of Correction
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Licensee agreed to obtain a new evacuation chair and install on the stairwell then provide LPA with a photo via email by COB 12/26/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Brian Balisi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2025


LIC809 (FAS) - (06/04)
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