567610022-9-25-2026-29-AS-BBAI-DY9SFX-20260925135103

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610022
Report Date: 09/25/2026
Date Signed: 09/25/2026 01:51:19 PM

Document Has Been Signed on 09/25/2026 01:51 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:	APPLETON HOMES		FACILITY NUMBER:	567610022
ADMINISTRATOR/ DIRECTOR:	OLIVAS, MYLINE		FACILITY TYPE:	740
ADDRESS:	1149 APPLETON RD		TELEPHONE:	(747) 237-0417
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 6		CENSUS: 5	DATE:	09/25/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Myline Olivas		TIME VISIT/ INSPECTION COMPLETED:	02:00 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. Upon arrival, the LPA met with staff and explained the reason for the visit. Administrator Myline Olivas arrived shortly after. LPA 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. At approximately 9:15 a.m., LPA inspected the kitchen and food service areas. Kitchen appliances were clean and operational. The facility maintained an adequate supply of perishable and non-perishable food. Food labels and expiration dates were reviewed. The Licensee maintains a list documenting the purchase and expiration dates of non-perishable foods. Knives and other sharps were locked and inaccessible to residents in a drawer to the left of the sink. LPA observed a resident eating breakfast in the dining area. The attached garage was inaccessible to residents and contained general storage, laundry equipment, an additional refrigerator/freezer for food storage, and a locked storage closet containing additional non-perishable and emergency food supplies. An office adjacent to the kitchen contained facility records stored inaccessible to residents. The entry closet contained incontinent supplies and PPE. Four (4) resident bedrooms were inspected and were appropriately furnished with clean linens, adequate lighting, and appropriate furnishings. Bedroom #1 was designated as a staff room, was empty, and was inaccessible to residents. Additional linens, books, board games, and resident activities were stored on shelving adjacent to Bedroom #2.

Desaree Perera
Brian Balisi
	DATE: 09/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026

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: APPLETON HOMES	FACILITY NUMBER: 567610022
	VISIT DATE: 09/25/2026

NARRATIVE

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Resident bathrooms were clean, sanitary, and operational. Bathrooms were equipped with grab bars, non-skid surfaces, and adequate supplies and paper towels. Hot water temperatures measured between 105°F and 120°F.

Common-area furniture was in good condition, and the facility temperature was maintained at approximately 72°F. Smoke and carbon monoxide detectors were operational. Fire extinguishers were fully charged and last serviced on 08/31/2026. The medication cabinet, located in the kitchen, was locked and inaccessible to residents. Exit auditory devices were operational. Required postings were observed throughout the common areas. The covered backyard area was equipped with resident-use furniture. No obstructions or loose items were observed in exits or common areas.

LPA reviewed five resident records, including appraisals, medical records, admission agreements, and consent forms. Four personnel records were reviewed, including health assessments, criminal record clearances, First Aid/CPR certification, and required training. Records reviewed were in order.
LPA reviewed medications for all residents.

Medications were properly stored and documented on the applicable Centrally Stored Medication and Destruction Record forms. LPA observed PRN authorization forms on file, all over the counter medications were observed complete with medication orders. No deficiencies were observed during the medication review at this time.

LPA reviewed the facility’s infection control practices and Emergency Disaster Plan. Infection control policies and procedures were adequate. Emergency disaster drills are conducted quarterly, with the most recent drill completed on 08/08/2026. The Emergency Disaster Plan was current and adequate. The Administrator reviews and updates the infection control and emergency disaster plans annually. Smoke and carbon monoxide detectors were tested and found operational. Staff also monitor hot water temperatures and smoke and carbon monoxide detectors monthly.

LPA conducted interviews and obtained current liability insurance documentation.

An exit interview was conducted, and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026

LIC809 (FAS) - (06/04)

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