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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610008
Report Date: 10/09/2026
Date Signed: 10/09/2026 11:54:23 AM

Document Has Been Signed on 10/09/2026 11:54 AM - 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HUMBLE HAVEN RCFE IIFACILITY NUMBER:
197610008
ADMINISTRATOR/
DIRECTOR:		JENNIFER PANTIGFACILITY TYPE:
740
ADDRESS:37801 Rudall AVETELEPHONE:
(707) 688-5606
CITY:PalmdaleSTATE: CAZIP CODE:
93550
CAPACITY: 6CENSUS: 5DATE:
10/09/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Jhune "Jasmin" BihasaTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Evelin Rios conducted a Case Management - Deficiencies visit in conjunction to complaint investigation #31-AS-20261008132208. During the visit, LPA reviewed six (6) resident files from 9:20 am to 11:00 am and observed files were not complete.

LPA's review of six (6) of six (6) resident files revealed three (3) residents, Resident #1 (R1), Resident #2 (R2) and Resident #6 (R6) are missing complete admission agreements with two (2) resident agreements are missing the licensee or the licensee's representative signature with date. The three (3) residents also did not have documented Pre Admission Appraisals. Six (6) of six (6) residents are missing documented Re-appraisals. Two (2) residents, R1 and R2, are missing an annual medical visit. R2 transferred out of the facility on 09/17/2026 but did not have a complete file while residing in the facility.

Deficiencies cited (refer to LIC809-D). Exit interview conducted, appeal rights discussed, and a copy of the appeal rights and this report was given to Jasmin.
Mary G Flores
Evelin Rios
DATE: 10/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2026
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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Document Has Been Signed on 10/09/2026 11:54 AM - It Cannot Be Edited


Created By: Evelin Rios On 10/09/2026 at 10:43 AM
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HUMBLE HAVEN RCFE II
FACILITY NUMBER: 197610008

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2026
Section Cited
CCR
87507(c)

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87507 Admission Agreements(c) Admission agreements shall be signed and dated, ... by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. This requirement is not met as evidenced by:
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R2 is no longer in the facility. R1's admission agreement will be signed and dated by the Licensee or the Licensees representative and a copy sent to the Department by POC due date 10/16/2026.
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Based on record review, the licensee did not comply with the section cited above in that 2 out of 6 residents did not have the licensee's signature with date on their admission agreement.
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Type B
10/16/2026
Section Cited
CCR87475(c)(1)(A)(B)

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87457 Pre-Admission Appraisal (c) Prior to admission ... (1) The appraisal shall document, at a minimum: (A) ... functional capabilities, mental condition, and social factors (B) ... allowed access to any of the items specified ... This requirement is not met as evidenced by:
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R2 is no longer in the facility. The Licensee will complete a pre admission appraisal for R1 and R6 for the record and a copy sent to the Department by POC due date 10/16/2026.
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Based on record review, the licensee did not comply with the section cited above in that 3 out of 6 residents did not have a Pre-Admission Appraisal documented on file.
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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.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/09/2026 11:54 AM - It Cannot Be Edited


Created By: Evelin Rios On 10/09/2026 at 11:04 AM
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HUMBLE HAVEN RCFE II
FACILITY NUMBER: 197610008

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2026
Section Cited
CCR
87463(a)

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87463 Reappraisals (a) The pre-admission appraisal ... shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, ... shall be referred to as the reappraisal. This requirement is not met as evidenced by:
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R2 is no longer in the facility. The Licensee will complete reappraisals for the five residents still in the facility and a copy sent to the Department by POC due date 10/16/2026.
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Based on record review, the licensee did not comply with the section cited above in that 6 out of 6 residents did not have reappraisals documented on file.
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Type B
10/16/2026
Section Cited
CCR87463(h)(1)(2)

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87463 Reappraisals (h) The licensee shall request that all residents receive an annual routine visit... (1) Documentation of the annual routine visit, ... shall be added to the resident's record. (2) Documentation of a resident's refusal ... shall be added to the resident's record.
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R2 is no longer in the facility. The Licensee will request R1 recieve an annual routine visit and obtain documentation for their record and a copy sent to the Department by POC due date 10/16/2026.
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This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in that 2 out of 6 residents did not have an annual rountine visit documented or refusal documented.
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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.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2026


LIC809 (FAS) - (06/04)
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