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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850332
Report Date: 06/04/2026
Date Signed: 06/04/2026 02:22:24 PM

Document Has Been Signed on 06/04/2026 02:22 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:INFINITY CARE HOMEFACILITY NUMBER:
565850332
ADMINISTRATOR/
DIRECTOR:		MANACAP, JOCELYNFACILITY TYPE:
740
ADDRESS:944 BELMONT AVENUETELEPHONE:
(805) 419-6012
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 4DATE:
06/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jocelyn ManacapTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced annual visit to this facility at 9:05 A.M., LPA met with caregiver Sheryl De Guzman. Administrator was contacted via telephone. At 9:10 A.M. Back-Up administrator Harold De Guzman arrived at the facility. Licensee/Administrator, Jocelyn Manacap, arrived at 9:45 A.M. Entrance interview conducted.

Beginning at 9:30 A.M., the LPA along with Back-up Administrator, 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. This facility doesn’t have a staff room; facility will provide 24/7 care. The following was observed:



BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three (3) total bedrooms, all of which are designated for shared resident use, at the time of the visit only Room #1 is being shared.

RESTROOMS: The LPA observed two (2) restrooms in the facility; one (1) is a shared restroom, and one (1) is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Between 9:41 A.M. and 9:46 A.M., hot water was above the regulation range. During today’s visit, back up Administrator adjusted the water heater.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2026
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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Document Has Been Signed on 06/04/2026 02:22 PM - It Cannot Be Edited


Created By: Valeria Conway On 06/04/2026 at 01:30 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: INFINITY CARE HOME
FACILITY NUMBER: 565850332

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 the hot water temperature meassured above the requiered regulation range of 120 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2026
Plan of Correction
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Back-Up Administrator adjusted the water heater during today's visit. POC Cleared.
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:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2026 02:22 PM - It Cannot Be Edited


Created By: Valeria Conway On 06/04/2026 at 01:31 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: INFINITY CARE HOME
FACILITY NUMBER: 565850332

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87469(a)
Advance Directives and Requests Regarding Resuscitative Measures
(a) Upon admission, a facility shall provide each resident, and representative or responsible person of each resident, with written information about the right to make decisions concerning medical care. This information shall include, but not be limited to, the Department's approved brochure entitled “Your Right To Make Decisions About Medical Treatment,” PUB 325, (3/12) and a copy of Sections 87469(b), (c) and (d) of the regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 3 out of 4 residents did not have required consent forms and/or personal rights form on their file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2026
Plan of Correction
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Licensee agreed to have all residents and/or responsible person to complete all necessary forms. Before POC due date, the licensee will provide proof that all forms were completed and signed to LPA.
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:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


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: INFINITY CARE HOME
FACILITY NUMBER: 565850332
VISIT DATE: 06/04/2026
NARRATIVE
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Continued from LIC 809

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room was observed to be in good condition. The LPA observed the required postings in the common area. Hardwired combination smoke and carbon monoxide detectors were tested by staff at 9:34 A.M. and were functional at the time of the visit. Fire extinguishers were observed to be fully charged and last serviced on 05/15/2026. Facility is equipped with two (2) fire doors to enhance safety and prevent the spread of fire. Both fire doors were observed closed during today’s visit. The facility serves residents with dementia, the auditory alarms on the exit doors were working properly during today’s visit. The facility maintained a temperature of 73 degrees. LPA observed a working phone available for residents use whenever needed.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPA conducted a review of expiration dates on product labels. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Cleaning compounds were stored under the kitchen sink and separately from food supplies. At 9:48 A.M., hot water measured at 131.9 degrees Fahrenheit. “Caution-Hot Water” warning signs were not visible. The Back-up Administrator stated that residents do not have access to, nor use, the kitchen sink. Temperature was adjusted during the visit.


OUTDOOR SPACE: The side yard has a covered outdoor area equipped with furniture for residents to enjoy. There were no bodies of water noted. Facility provides sufficient space to accommodate both indoor and outdoor activities. Facility has two total gates; both were observed to be self-closing and self-latching gates with clear passageways for emergency exit use.

GARAGE: The garage was observed locked. LPA observed extra non-perishable food, and a refrigerator with extra food. Furthermore, laundry area, as well as emergency food supply and water, and storage space were observed in the garage. All cleaning compounds were stored in areas separately from food supplies. LPA reminded administrator that given that there are no staff rooms, the facility is required to have 24/7 care, and that staff cannot use the garage or a common area to sleep.

Continued on LIC 809-C

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

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
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: INFINITY CARE HOME
FACILITY NUMBER: 565850332
VISIT DATE: 06/04/2026
NARRATIVE
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Continued on LIC 809-C

RECORD REVIEW: Began at 10:30 A.M., staff and resident 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. LPA reviewed four (4) resident records for regulatory compliance. During the review, LPA observed that three (3) out of four (4) residents had incomplete consent for medical treatment forms and personal rights forms. LPA reminded Administrator that Needs and Service Appraisal shall be conducted when a resident has a change of condition or once every 12 months. LPA reviewed five (5) staff files including the administrator. All files reviewed were complete and in compliance with regulations.

MEDICATION REVIEW: All medications are kept in a hallway closet. This closet is locked at all time and medication is inaccessible to residents. LPA observed a complete 1st aid kit including its manual inside that closet. Audit began at 12:30 P.M. Medications for all residents were observed to be in compliance with Title 22. Record review revealed that the physician's report for Resident #1 (R1) indicates R1 can store and self-administer their medication. The facility maintains bulk medication storage; however, according to Administrator, it is R1’s preference to use a weekly pill organizer that is kept in their room. Staff stated that R1 independently administers their medication from the weekly pill organizer. LPA did not audit R1’s medication.

Infection Control/Emergency Disaster Planning: The LPA reviewed the facility's infection control plan and the emergency disaster plan. The facility’s policies and procedures as they pertain to infection control and emergency disaster plan are adequate. Emergency disaster drills are being conducted quarterly with the last drill conducted on 05/04/2026.

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: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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