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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609650
Report Date: 07/08/2025
Date Signed: 07/16/2025 12:34:03 PM

Document Has Been Signed on 07/16/2025 12:34 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:CLARKS RESIDENTIAL CARE HOME LLCFACILITY NUMBER:
567609650
ADMINISTRATOR/
DIRECTOR:		CARINO II, RICHARD TFACILITY TYPE:
735
ADDRESS:4525 READING DRTELEPHONE:
(805) 246-8446
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 4CENSUS: 4DATE:
07/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Charles “Martin” Carino TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. LPA met with facility staff, Yeoman Edrada, who contacted administrator Charles “Martin” Carino via telephone. LPA explained the reason for today's visit. Entrance interview conducted. On 7/16/25 LPA Conway conducted a subsequent visit to gather signatures for amended report and deficiency pages.

The facility is vendored through Tri-Counties Regional Center as a level 4I home.

During today’s visit, LPA along with facility administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This facility doesn’t have a staff room, facility will provide 24/7 care. The following was observed:



The hardwired carbon monoxide and smoke alarms were tested at 11:50 AM and all functioned properly. The fire extinguisher was observed to be fully charged and last serviced on 11/20/2024.

KITCHEN: Knives are stored in a locked drawer. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medications were observed to be in a locked cabinet located within the kitchen.

BEDROOMS: The LPA observed four single-occupancy client bedrooms, all of which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2025
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 6
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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Document Has Been Signed on 07/16/2025 12:34 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/14/2025 02:13 PM


Created By: Valeria Conway On 07/08/2025 at 03:15 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CLARKS RESIDENTIAL CARE HOME LLC
FACILITY NUMBER: 567609650

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1531.15(g)
Regulations
(g) Secured perimeters shall not substitute for adequate staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Please refer to the supportive information report (812) created on 07/14/25, for additional details related to removal of this deficiency
POC Due Date: 07/08/2025
Plan of Correction
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Deficiency removed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/16/2025 12:35 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/14/2025 02:19 PM


Created By: Valeria Conway On 07/08/2025 at 03:15 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CLARKS RESIDENTIAL CARE HOME LLC
FACILITY NUMBER: 567609650

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)(1)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having a current ledger of client's cash resources which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2025
Plan of Correction
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Administrator will update cash resources ledger/log and submit to LPA before POC due date.
Type B
Section Cited
CCR
85165(h)
Emergency Intervention Staff Training
(h) The licensee shall maintain a written record of the staff training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Please refer to the supportive information report (812) created on 07/14/25, for additional details related to removal of this deficiency
POC Due Date: 07/22/2025
Plan of Correction
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All staff has sufficient training including PRO-ACT.
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: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2025


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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CLARKS RESIDENTIAL CARE HOME LLC
FACILITY NUMBER: 567609650
VISIT DATE: 07/08/2025
NARRATIVE
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Continued from LIC 809

RESTROOMS: Restrooms are clean and sanitary and in operating condition. Hot water was checked in the private resident restroom and measured at 118.2 degrees Fahrenheit. Water temperature was checked in the common restroom and was measured at 108.3 degrees Fahrenheit. Both were measured within the required range. Showers were observed to contain slip-resistant surfaces and mats. LPA observed that both restrooms did not have paper towels available in the designated paper towel dispensers at the time of the visit. Technical Violation (TV) issued

COMMON SPACES: Living room, tv room, and dining room furniture was observed to be in good condition. The LPA observed all required postings upon entry. Games are available for resident use located in the TV room. A properly screened fireplace was observed in the dining room.

OUTDOORS: LPA toured outdoor areas. Tables and chairs were observed with appropriate shading. A shed was observed to be locked. The facility has a side gate that was free from obstruction.

GARAGE: Garage was observed to be utilized as an activity space for clients. The garage contained laundry areas with locked chemical storage. The garage contained adequate emergency food and water supplies.

CLIENT FILES/CASH RESOURCES: LPA reviewed all 4 (four) client files for, but not limited to: physician's report, proof of TB test, Admission Agreement, and cash resources. All 4 (four) client files reviewed were complete and contained all documentation required. Cash resources were reviewed, LPA observed that two (2) clients cash resources record did not have a current ledger.

MEDICATION REVIEW: Beginning at 2:32 PM, LPA reviewed medications for 2 (two) clients. All medications reviewed were documented and stored in compliance with regulation.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: CLARKS RESIDENTIAL CARE HOME LLC
FACILITY NUMBER: 567609650
VISIT DATE: 07/08/2025
NARRATIVE
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Continued from LIC 809-C

STAFF FILES: LPA reviewed files for 4 (four) staff members. All staff files contained all required document up to date, including training, 1st aid/CPR, Personnel record (LIC 501) and Health Screening Report (LIC 503) with TB test results.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: LPA reviewed the facility’s emergency disaster plan and infection control plan. The facility’s emergency disaster plan is adequate and reviewed annually. The last emergency disaster drill was conducted on 06/16/2025. The facility’s practices as it pertains to infection control are adequate.

INTERVIEWS: During today's visit, LPA attempted to interview one (1) client present, however they were sleeping during today’s visit. LPA interviewed one (1) staff member. Staff understood their roles, clients rights, and the forms of abuse as well as the proper reporting procedures.

During today's visit LPA obtained a copy of the facility's surety bond, staff schedule, resident roster, and liability insurance.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Licensee was advised that failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the 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: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
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