565850572-12-5-2025-29-AS-BBAI-DP3UPK-20251205144539

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850572
Report Date: 12/05/2025
Date Signed: 12/05/2025 02:47:21 PM

Document Has Been Signed on 12/05/2025 02:47 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:	MEDO PEACEFUL HOME		FACILITY NUMBER:	565850572
ADMINISTRATOR/ DIRECTOR:	TAYEBWA, ONESMUS		FACILITY TYPE:	735
ADDRESS:	2274 WALDO STREET		TELEPHONE:	(818) 770-9074
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 4		CENSUS: 4	DATE:	12/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Emmanuel Kangala		TIME VISIT/ INSPECTION COMPLETED:	03:00 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) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. LPA met with facility staff and explained the reason for the visit. Facility Administrator Emmanuel Kangala arrived shortly after. At approx 09:50a.m. LPA along with the facility 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: LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a fire extinguisher to be fully charged and purchased within the year. There are four (4) bedrooms in the facility. All four (4) resident bedrooms are private rooms. LPA and the facility staff member toured all four (4) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, emergency flashlights, and sufficient lighting. Bedroom number four (4) contains a direct exit to the outside of the facility. There is an attached garage that was inaccessible to clients in care. LPA observed the garage to contain an extra freezer, adequate amount of emergency food and water. LPA also observed a locked storage cabinet for cleaning supplies. There are two (2) bathrooms at the facility. Both are designated as a common resident bathrooms. All bathrooms were observed to be clean and were equipped with nonskid surfaces. LPA observed both bathrooms to contain locked under sink cabinets. The cabinets contained personal grooming supplies. The water temperature was measured in all bathrooms between 105 degrees Fahrenheit and 120 degrees Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

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: MEDO PEACEFUL HOME	FACILITY NUMBER: 565850572
	VISIT DATE: 12/05/2025

NARRATIVE

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LPA observed common areas including living room, dining room, and laundry room. The living room to be clean and properly furnished at the time of the visit. LPA observed the living room to contain a couch, television, and activities for resident use. The dining room was observed to be clean and contains adequate seating for resident use. The hallway was observed to contain three (3) properly secured cabinets. One secured cabinet contained resident medications, first aid supplies, and activity supplies. The other secured cabinets contained clean linens and cleaning chemicals. The facility has one (1) emergency exit gate, LPA observed clear passageways for emergency exit use. The facility has adequate shaded outdoor seating for client use.

Records review, client Records were reviewed for documents including, but not limited to: health screening, TB test, resident physician's report, needs and service appraisal, consent forms, and personal rights. Four (4) client files were reviewed.

At approx 10:15 a.m. LPA's file review of Client #1 (C1)s file revealed C1 was admitted into the facility on 01/24/2025. C1's Physicians Report dated 01/11/2025 revealed C1 is listed as Non-Ambulatory. The home is licensed for Ambulatory only. Administrator contacted C1's Primary Care Physician's office, which stated C1 was listed as "Non-Ambulatory" in error. The Administrator was advised by the office staff to make a new appointment for C1 so they can issue an updated Physician's Report. During the visit LPA observed C1 sitting in a wheelchair. Administrator spoke with Westside Regional Center and updated them regarding status of C1's current Physician's report. Administrator also contacted the local fire inspector during the visit.

Staff files were reviewed for documents including, but not limited to: staff training records, fingerprint clearance, TB tests and criminal record clearance. Six (6) staff files were reviewed. All staff files contained the required documents and training's.

Medication review, medications for four (4) of four (4) clients were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. Cash resources were reviewed for clients in care. All cash resources were documented appropriately and accurately and were accompanied by corresponding purchase receipts. No deficiencies were observed during cash resource review.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

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: MEDO PEACEFUL HOME	FACILITY NUMBER: 565850572
	VISIT DATE: 12/05/2025

NARRATIVE

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Continued from 809-C

Infection control / Emergency Disaster plan: 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. Emergency disaster drills are to be conducted quarterly; the facility’s last emergency disaster drill was conducted on 11/13/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator. Smoke detectors and carbon monoxide detectors were tested, all alarms and the facility’s fire door were functional at the time of the visit.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 809-D.) Civil penalty in the amount of $500 was issued due to a fire clearance violation. 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: 12/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/05/2025 02:47 PM - It Cannot Be Edited

Created By: Brian Balisi On 12/05/2025 at 01:52 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: MEDO PEACEFUL HOME	FACILITY NUMBER: 565850572
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80020(a)

Fire Clearance

(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as the licensed is approved for Ambulatory only and C1 is listed as Non-Ambulatory at this time, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/08/2025
	Plan of Correction
1 2 3 4	During the visit, the Administrator contacted the fire marshal and Westside Regional Center. Administrator also contacted C1's primary care physician and made an appointment to reevaluate C1 ambulatory status. Administrator agreed to review section cited and provide LPA with a written plan to ensure future compliance then send to LPA via email by COB 12/08/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 12/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

LIC809 (FAS) - (06/04)

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