<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850432
Report Date: 08/11/2025
Date Signed: 08/11/2025 02:02:18 PM

Document Has Been Signed on 08/11/2025 02:02 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:PEORIA NEW LIFE HOMEFACILITY NUMBER:
565850432
ADMINISTRATOR/
DIRECTOR:		NASSANGA, FATUMAFACILITY TYPE:
735
ADDRESS:3127 PEORIA AVETELEPHONE:
(818) 324-9589
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 4CENSUS: 4DATE:
08/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Fatuma NassangaTIME VISIT/
INSPECTION COMPLETED:
02:15 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) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today. Upon arrival, the LPA was greeted by staff who then contacted the Administrator, Fatuma Nassanga via telephone and at this time, the reason for the visit was explained. Designated staff, Isaac Barya arrived at approximately 10:38am. Entrance interview conducted.

Starting at 10:40am, the LPA along with designated staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Kitchen: The LPA observed the kitchen/food area at approximately 10:56am. The kitchen appliances appeared to be clean and in operable condition. The facility has a sufficient supply of non-perishable and perishable food; properly stored. Refrigerator and dry food pantry were checked for proper labels and expiration dates. Knives and sharps were in a locked cabinet adjacent to the dining room. The water temperature was measured in the kitchen sink, and it measured 110.4 degrees Fahrenheit at 10:59am.

Bedrooms: There are four (4) bedrooms designated for client use. The LPA observed all client bedrooms to be properly furnished and with sufficient lighting. There is a closet in the hallway with additional clean linens and towels for client use. Personal hygiene items were observed locked and inaccessible at the time of the visit. Staff bedrooms observed on premises locked and inaccessible to clients at the time of the visit.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2025
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 4
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)
Page: 2 of 4
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: PEORIA NEW LIFE HOME
FACILITY NUMBER: 565850432
VISIT DATE: 08/11/2025
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
26
27
28
29
30
31
32
Report Continued from LIC 809...

Bathrooms: There are a total of four (4) bathrooms. Three (3) bathrooms are designated for client use and one (1) bathroom for staff use only. Client bathrooms were observed to be equipped with nonskid surfaces and grab bars. The LPA observed bathrooms to be clean, properly supplied with soap and paper towels, and had functional fixtures. Starting at 10:47am., the water temperature was measured in all client bathrooms, and they measured between 106.9 and 117.8 degrees Fahrenheit.

Common Areas: The LPA observed the living room and dining room area to be furnished appropriately, and all furniture was observed to be in good condition at the time of the visit. The facility maintained a comfortable temperature. The LPA observed required postings throughout the common space. Activities for clients were observed in the living room. There is a working telephone on premises. The LPA observed two (2) fireplaces which were adequately covered. The facility has an adequate amount of emergency food and water. At 11:07am, the smoke detector and carbon monoxide detector were tested and were operational at the time of the visit. No obstructions or hazards were observed inside or out.

Garage: The garage is attached to the facility and kept unlocked at all times. Additional cleaning supplies were observed in a locked cabinet inaccessible to clients in care.

Laundry: The washer and dryer were observed adjacent to the kitchen. Cleaning supplies and toxins were observed in a locked cabinet inaccessible to clients at the time of the visit.

Outdoors: There is a shaded area in the backyard with appropriate furniture for client use. There is one (1) shed used for storage purposes which was observed to be locked at the time of the visit. The exterior passageways were clean and clear of any obstructions at the time of the visit. The LPA observed two (2) latching gates for emergency use. No bodies of water noted at the time of the visit.

Record Review: The LPA reviewed four (4) Client Records and five (5) Personnel Records including the Administrator’s file starting at 11:20am.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: PEORIA NEW LIFE HOME
FACILITY NUMBER: 565850432
VISIT DATE: 08/11/2025
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
26
27
28
29
30
31
32
Report Continued from LIC 809C...

Client 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/IPP. All files were complete.

Personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR certifications, and yearly necessary training. All records were in order.

Administrator’s Certificate is active until 08/20/2026.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 4i home.

During today’s visit, the LPA conducted an interview with one (1) staff.

Infection Control / Emergency Disaster Planning: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Fire extinguisher was observed to be fully charged and serviced on 04/14/2025. Emergency disaster drills are being conducted at least once per quarter; last fire drill conducted on 07/13/2025.

Medication Review: The LPA conducted a medication review at approximately 12:30pm. Medications are centrally stored in a locked cabinet adjacent to the dining room. All medications including PRNs were labeled, stored, and locked inaccessible to client in care. Medications appear to be given as prescribed at the time of the visit.

No citations issued. Exit interview conducted. Copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4