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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850346
Report Date: 11/30/2023
Date Signed: 11/30/2023 11:02:38 AM

Document Has Been Signed on 11/30/2023 11:02 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MOM'S PLACE IFACILITY NUMBER:
565850346
ADMINISTRATOR:JOSE, JOSEPHFACILITY TYPE:
740
ADDRESS:4 MANSFIELD LANETELEPHONE:
(818) 274-1809
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 0DATE:
11/30/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Oyewole Joseph JoseTIME COMPLETED:
10:57 AM
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An office meeting was conducted at the Woodland Hills North Adult and Senior Care Regional Office (RO). The purpose of today’s meeting was to discuss the license applications pending as well as the Licensee’s newly-licensed facilities within the RO’s jurisdiction. Present at today’s meeting were: Oyewole (Joseph) Jose, Licensee, Jill Nakata, Regional Manager (RM), KaSandra Lopez, Licensing Program Manager (LPM), and Kelly Dulek, Licensing Program Analyst (LPA). Additionally, telephonically present were: Kristin Heffernan, Licensing Program Manager (LPM) and Desaree Perera, Licensing Program Manager (LPM).

The Licensee is responsible for the following currently licensed facilities: Clarendon Senior Living 2, Clarendon Senior Living 3, Mali’s Place I, Mali’s Place II, Omnicare, Omnicare II, and Sunshine Residential Home Balboa. The Licensee is also responsible for the following pending applications: Mom’s Place 2, Mom’s Place 3, Mom’s Place I, Omnicare III, Sally’s Residential Care Home, Sally’s Residential Care Home 2, Sally’s Residential Care Home 3, and Sally’s Residential Care Home 4. There are an additional 15 facilities, both pending and currently licensed, outside this RO’s jurisdiction the Licensee is responsible for.

During today’s meeting, RM, LPM, and LPA discussed the following topics:



· Construction plans/physical plant concerns and the corresponding communication with CCL and residents/responsible parties. RM reminded licensee to ensure proper construction permits are obtained.
· Communication with CCLD – RO and Centralized Application Bureau (CAB)
· Administrator plan for the Licensee’s facilities - Licensee previously provided LPA with 3 (three) potential Administrators, 2 (two) of which have pending Administrator Certificates. RO will follow up with Administrator Certification section.
· Spreading thin of the Licensee. Ensure Management team is in place to support the growth of the business.
· LLCs listed as the Licensee – one shows as inactive. Clarification on which LLCs should be listed.
Report Continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MOM'S PLACE I
FACILITY NUMBER: 565850346
VISIT DATE: 11/30/2023
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  • Managing members of the corporations, a plan to ensure continuity/backup in case of emergency.
· Change of Ownership applications and Interim Management Agreements for pending applications.

The Licensee discussed:

· The construction contract with the current contractor included measures to keep the residents safe, but that doesn't appear to be what has happened. Licensee will stop work immediately and revisit when there is a relocation site to ensure health and safety of the residents in care.


· Joseph had an agreement with the current licensees for them to continue to manage operations for their facilities until they closed escrow and the current licensees changed the plan.
· Administrators had to renew or apply for new certificates, which is taking a lot of time to process.
· 12 Admins on his team at this point and a day program director. 30 total facilities licensed and/or pending at this point.
· Currently, Joseph Jose is the only managing member of the LLCs currently, but that will change. Joseph understands over majority change, needs to go through CAB. Have a lot of RCFEs that can use a management company and Joseph is aware of how to add a management company to the License.
· Joseph met with CAB supervisors this summer – he asked to have just 1 or 2 analysts looking at the applications would be helpful to streamline the process.
· Joseph discussed transparency with both the Department and families and ensuring best practices for communication going forward.

The following documents were provided to the Licensee:
  • Health and Safety code 1569.191 related to sale of licensed facilities.
  • Reporting requirements and the documents needed to change an Administrator.
  • Copies of the LIC 308 and LIC 500


Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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