565850614-6-2-2026-29-AS-VCOY-DUP6GV-20260602204832

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850614
Report Date: 06/02/2026
Date Signed: 06/02/2026 08:50:28 PM

Document Has Been Signed on 06/02/2026 08:50 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:	CLUBHOUSE HAVEN, THE		FACILITY NUMBER:	565850614
ADMINISTRATOR/ DIRECTOR:	CACAL, JOCELYN		FACILITY TYPE:	740
ADDRESS:	4104 CLUBHOUSE DRIVE		TELEPHONE:	(512) 592-9001
CITY:	SOMIS	STATE: CA	ZIP CODE:	93066
CAPACITY: 6		CENSUS: 6	DATE:	06/02/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:55 AM
MET WITH:	Jocelyn Cacal		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

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At 9:55 A.M. Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced annual inspection of the above-listed facility. Upon arrival LPA met with Licensee, Jocelyn Cacal and the reason for the visit was explained. Entrance interview conducted.

At 10:00 A.M., LPA along with Licensee conducted a facility plant tour. Fire extinguisher was observed to be fully charged and last purchased on 06/10/2025. At 10:34 A.M. hardwire smoke detectors and carbon monoxide detectors were tested and were functional at the time of the visit. Facility is equipped with two (2) fire doors to enhance safety and prevent the spread of fire. During today’s visit, Licensee stated that a third-party company is scheduled to install magnetic hold devices on each fire door to remain open during business hours.

Bedrooms: The facility consists of six (6) private resident bedrooms and one (1) staff room. Auditorial signal system was observed in each door around the facility. All bedrooms were furnished appropriately with clean linen, appropriate furnishings and sufficient lighting. No resident bedroom will be used as a public or general passageway to another room, bath, or toilet.

Bathrooms: The facility consists of seven (7) bathrooms. Three (3) are shared bathrooms and four (4) are located inside Room #2, # 3, #4 and #5. LPA observed that the hand washing sink located in the shared bathroom across from room #1 did not drain properly while the faucet was running. Technical Violation (TV) issued. During today's visit the sink was fixed.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CLUBHOUSE HAVEN, THE	FACILITY NUMBER: 565850614
	VISIT DATE: 06/02/2026

NARRATIVE

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Continued from LIC 809

LPA observed all bathrooms to have grab bars and slip-resistant floors and mats. Between 10:14 A.M. and 10:27 A.M. hot water temperatures were measured in all bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit.

Common Areas: These include the Foyer, Entertainment Room, Living Room and Dining Room. The common areas were checked for cleanliness and furniture was checked for functionality. At the time of the visit, LPA observed locked cabinets located in the entertainment room designated to store residents’ medications and first aid kit. The facility has a fireplace, at the time of the visit, LPA observed the fireplace properly screened. LPA observed night lights in all hallways and passages. The facility maintained a temperature of 75 degrees Fahrenheit. LPA observed that all required posters were posted. LPA observed a working camera recorder facing the main entrance. Licensee stated that camera does not record sound.

Kitchen: The kitchen appeared clean. There was a sufficient supply of perishable and non-perishable food. LPA conducted a review of expiration dates on product labels. Appliances appear to function properly. Knives are stored locked in a kitchen drawer. At 10:03 A.M., hot water measured 132.8 degrees Fahrenheit. The LPA did not observe a warning sign posted at the sink. The Licensee stated that residents do not have access to, nor use, the kitchen sink. Technical Violation (TV) issued. Licensee posted a "Hot Water" warning sing on the kitchen window above the kitchen sink.

LAUNDRY ROOM: LPA observed a washer and a dryer machine and a sufficient amount of emergency water. Staff will assist residents with all laundry needs. Furthermore, LPA observed several locked cabinets where chemical, hygiene products and cleaning supplies are be stored.

Detached Garage and Surrounding Grounds: A detached garage was observed to store extra supplies and gardening tools. The front and back yards are easily accessible to residents, and they are sufficient in size, comfortable and appropriately equipped. There was a shaded area with proper furniture for outdoor use. LPA observed sufficient space to accommodate outdoor activities for residents and an electric self-closing gate. There are no bodies of water on the premises.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

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: CLUBHOUSE HAVEN, THE	FACILITY NUMBER: 565850614
	VISIT DATE: 06/02/2026

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Continued on LIC 809-C

RECORD REVIEW: Between 11:55 A.M. and 2:00 P.M., staff and resident records were reviewed. Facility staff and residents’ files are stored in a locked file cabinet in the foyer. Six (6) resident and six (6) personnel 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, health assessments, criminal record clearances, first aid/CPR training, and appropriate training. All staff files were completed. During the resident record review, the LPA observed that one (1) resident’s Needs and Service Plan was incomplete. Additionally, the LPA observed that (3) out of six (6) resident’s Needs and Services Appraisal were missing either the resident’s signature or the signature of the resident’s responsible person.

MEDICATION REVIEW: Medications are locked in cabinets located in the entertainment room. Between 2:10 P.M. and 3:15 P.M., medications for six (6) residents were audited. During the medication audit, the LPA observed that two (2) prescribed medications administered to Resident #1 were not listed on the Centrally Stored Medication and Destruction Record (LIC622) or the Medication Administrator Record (MAR). Record review and medication packages confirmed that the medication had been administered as prescribed. Technical Violation (TV) issued. Each resident's medication was observed stored in its originally received container.

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. LPA requested a copy of both plans to be filed with the Regional Office.

During today’s visit, LPA requested the Personnel Report (LIC500), the resident’s rooster (LIC9020), liability insurance and last emergency drill. Last emergency drill was conducted on 04/18/2026

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: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/02/2026 08:50 PM - It Cannot Be Edited

Created By: Valeria Conway On 06/02/2026 at 03:55 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: CLUBHOUSE HAVEN, THE	FACILITY NUMBER: 565850614
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(i)

Reappraisals

(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as four (4) out of six (6) residents did not have a complete Needs and Service Appraisal which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/16/2026
	Plan of Correction
1 2 3 4	Licensee agreed to complete and have responsible persons sign current Needs and Service Appraisal for all 4 residents. Licensee will submit evidence of completion before POC due date.

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:

	Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC809 (FAS) - (06/04)

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