565850416-3-23-2026-29-AS-MARO-DSFSYR-20260323141757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850416
Report Date: 03/23/2026
Date Signed: 03/23/2026 02:18:10 PM

Document Has Been Signed on 03/23/2026 02:18 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:	MARICAR'S MANOR II		FACILITY NUMBER:	565850416
ADMINISTRATOR/ DIRECTOR:	AMBER WINTERSTEIN		FACILITY TYPE:	740
ADDRESS:	1168 ARCANE STREET		TELEPHONE:	(805) 210-2480
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 6		CENSUS: 5	DATE:	03/23/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Maricar Lee		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct the required annual visit today at 09:30 a.m. Upon arrival, the LPA was greeted by staff who then contacted the Licensee Representative telephonically and informed them of today’s visit. The Licensee Representative, Maricar Lee arrived at approximately 10:20 a.m. Entrance interview conducted.

Beginning at 10:25 a.m., the LPA along with the Licensee Representative 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:

Kitchen: The LPA inspected the kitchen/food service area at approximately 10:35 a.m. Knives and sharps were observed in a kitchen drawer locked and inaccessible at the time of the visit. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates.

Common Areas: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed two (2) fire extinguishers to be fully charged with a charge date of 07/28/2025. Fireplace was observed adequately covered at the time of the visit. Required postings were observed throughout the common space. There is a working telephone on premises. Activities were observed in the common areas. At 10:43 a.m., the smoke detector and carbon monoxide were tested and operational at the time of the visit. hazards/obstructions observed inside or out.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2026

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: MARICAR'S MANOR II	FACILITY NUMBER: 565850416
	VISIT DATE: 03/23/2026

NARRATIVE

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Report Continued from LIC 809...

Restrooms: There are two (2) restrooms for residents’ use. One (1) bathroom is located inside bedroom #1 and second bathroom was observed by the main hallway. Bathrooms were clean and sanitary and in operating condition with non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:28 a.m., the hot water temperature was measured in both bathrooms, and they measured within the required range of 105 – 120 degrees Fahrenheit.

Bedrooms: There are three (3) bedrooms for resident use and are designated as shared / double occupancy bedrooms. Bedrooms were observed to be furnished appropriately and had sufficient lighting. Additional clean linens and towels were observed in a closet by the hallway. Staff bedroom was observed locked and inaccessible at the time of the visit.

Garage/Laundry Room: The garage is accessible directly from the main house. Garage was locked at the time of the inspection. Washer and dryer were observed inside the garage. Cleaning supplies and detergents were observed locked and inaccessible at the time of the visit. The LPA observed an adequate amount of emergency food and water.

Outdoors: The backyard has a covered patio area with adequate furniture for resident use. Emergency passageway was observed to be clear of any obstructions. There is one (1) side gate with latching mechanisms. No bodies of water noted at the time of the visit.

Records: Record review began at approximately 10:55 a.m.

Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, consent for treatment form, and current needs and services plan. Files were in order.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2026

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARICAR'S MANOR II	FACILITY NUMBER: 565850416
	VISIT DATE: 03/23/2026

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Report Continued from LIC 809C...

Three (3) personnel files were reviewed for, but not limited to: personnel records, health assessments with negative TB test results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. Personnel files were complete.

Infection Control / Emergency Disaster Planning: The LPA reviewed the facility's infection control plan and emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. The LPA observed the emergency disaster plan to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; last drill conducted on 03/02/2026.

Medications: Medications review began at approximately 01:45 p.m. Medications are centrally stored and kept in a locked cabinet adjacent to the kitchen. Medications are properly documented on the centrally stored medication and destruction record. Medications appear to be administered as prescribed at the time of the visit.

No citations issued at this time. Exit interview conducted. Report was reviewed and copy provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2026

LIC809 (FAS) - (06/04)

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