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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610274
Report Date: 09/09/2026
Date Signed: 09/09/2026 01:19:59 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/09/2026 01:19 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:FOREVER LOVE HOME CARE INC.FACILITY NUMBER:
197610274
ADMINISTRATOR/
DIRECTOR:		BELMONTE, MARKFACILITY TYPE:
740
ADDRESS:44920 LOTUS LN.TELEPHONE:
(661) 206-7518
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 4DATE:
09/09/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Mark Belmonte- AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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On 9/09/2026 at approximately 10:20 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the Administrator, Mark Belmonte and stated the reason for their visit.

LPA asked for the census, Staff/Resident Roster, and Liability Insurance. LPA conducted a physical plant tour at approximately 12:00 PM and the following was noted:

The facility is a single-story building with six (6) bedrooms and three (3) bathrooms. The facility is currently occupying four (4) residents. There is a designated staff room. The facility has an approved fire clearance for six (6) non-ambulatory residents of which one (1) may be bedridden. Hospice waiver approved for four (4).

Common areas: The living rooms and dining room were observed to be neat, clean, and organized. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 73°F. LPA observed a fire extinguisher to be located near the kitchen and dated 01/13/2026. LPA observed required postings such as Long-Term Care Ombudsman, See/Say Something, and Personal Rights to be located throughout the common areas. A working telephone was observed. LPA observed the fireplace to be covered and inaccessible to residents.

Kitchen: The kitchen was observed to be clean and free from pests. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. Knives/sharps were observed to be kept in a locked kitchen drawers. The cleaning solutions/toxins were observed to be kept locked underneath the kitchen sink. Kitchen appliances were observed to be working and in proper condition. (continued on LIC 809-C)

Troy Agard
Angelica Segovia
DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2026
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: FOREVER LOVE HOME CARE INC.
FACILITY NUMBER: 197610274
VISIT DATE: 09/09/2026
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Bedrooms: The residents’ rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Extra linens/covers were observed to be stored in a closet located within the hallway’s passageway.

Bathrooms: The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured within regulations. LPA observed appropriate grab rails and slip-resistant mats to be in proper condition.

Backyard: The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. LPA observed there to be a shed. There is no body of water located at the facility.

Laundry Room: The laundry room was observed to be kept locked. The laundry appliances were observed to be in proper condition. LPA observed cleaning solutions and toxins stored appropriately within the laundry room and inaccessible to residents. Garage: The garage can be accessed from inside of the facility and observed to be located next to the laundry room. The garage was observed to be kept locked and used for storage purposes. Extra refrigerators with additional food for residents was observed.

Medications: The medications were observed to be kept in locked cabinets located in the kitchen. First-aid kit observed to be equipped with but not limited to bandages, digital thermometer, tweezer and First-Aid Manuel.

Smoke detectors and carbon monoxide observed to be working properly and were tested.

Residents/Staff Records: LPA conducted a complete file review of resident records. Resident records appeared to be complete. Staff records: LPA conducted a complete file review of two (2) staff records. Staff records appeared to be complete and updated.

LPA observed a former residents medication to be stored in the staff room which was observed to be unlocked.

Citation issued. Please refer to LIC 809-D. LPA along with the Administrator created the Plan of Correction (POC) regarding the citation.

There were no other immediate health and safety hazards observed during the day of inspection.

Exit interview was conducted, appeal rights given, and a copy of this report was provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2026 01:19 PM - It Cannot Be Edited


Created By: Angelica Segovia On 09/09/2026 at 12:51 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOREVER LOVE HOME CARE INC.
FACILITY NUMBER: 197610274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2026
Section Cited
CCR
87465(i)

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87465 Incidental Medical and Dental. (i) Prescription medications which are not taken with the resident upon termination of services... shall be destroyed in the facility by the facility administrator and one other adult who is not a resident.
This requirement was not met evidenced by:
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The Administrator/Licensee will review the regulation and email LPA Segovia a statement of understanding along with record of destruction of medication.
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Based on interviews, record review and observations 1 of 1 former resident's medication had not been destroyed and was kept in unlocked staff room which poses an immediate health, safety or personal rights risk to persons in care.
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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.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Angelica Segovia
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2026


LIC809 (FAS) - (06/04)
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