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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604820
Report Date: 09/03/2026
Date Signed: 09/03/2026 01:13:27 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/03/2026 01:13 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:NEW WORLD VILLA SOUTHFACILITY NUMBER:
374604820
ADMINISTRATOR/
DIRECTOR:		CHEN, ZAYDENFACILITY TYPE:
740
ADDRESS:14125 TARZANA RDTELEPHONE:
(858) 748-2888
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 2DATE:
09/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:57 AM
MET WITH:Caregiver Victoria Bayani
Caregiver Florencia Pangilinan		TIME VISIT/
INSPECTION COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Angelica Boyles and Patrice Bazemore conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Victoria Bayani and Caregiver Florencia Pangilinan. LPAs also spoke with Administrator Shamila Yasar over the phone.

LPAs, accompanied by caregiver, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperatures in bathrooms accessible to residents were recorded at the following temperatures in Fahrenheit: 128.8, 125.0, 140.0, 146.5.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. LPAs observed medications not stored in original packaging as well as medications that were not destroyed upon a resident's death on 8/31/26.



(CONTINUED ON LIC 809C)
Simon Jacob
Angelica Boyles
DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2026
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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: NEW WORLD VILLA SOUTH
FACILITY NUMBER: 374604820
VISIT DATE: 09/03/2026
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(CONTINUED FROM LIC 809)

No pools or bodies of water were observed on the premises. Per Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPAs reviewed multiple staff and resident records/files. Staff files reviewed did not contain required documents. Confidential records were not stored in locked areas. Proof of current/active business liability insurance was presented.



Seven deficiencies and one Technical Violation were observed during today's visit per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages and LIC9102). A plan of correction was jointly developed with Administrator.

An exit interview was conducted with Administrator Shamila over the phone and Caregiver Flor signed for. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Angelica Boyles
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026
LIC809 (FAS) - (06/04)
Page: 7 of 7
Document Has Been Signed on 09/03/2026 01:13 PM - It Cannot Be Edited


Created By: Angelica Boyles On 09/03/2026 at 11:56 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NEW WORLD VILLA SOUTH
FACILITY NUMBER: 374604820

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2026
Section Cited
CCR
87303(e)(2)

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Maintenance and Operation
(e) Water supplies...shall be maintained as follows: (2) Faucets used by residents...shall deliver hot water. Hot water temperature controls shall...attain a temperature of not less than 105 degree F...and not more than 120 degree F...
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Facility staff agreed to adjust the water heater temperature by POC due date.
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This requirement was not met as evidenced by:
LPAs measured sinks accessible to residents at the following temperatures: 128.8, 125.0, 140.0, and 146.5. This poses an immediate health and safety risk to 2 of 2 residents in care.
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Type B
09/14/2026
Section Cited
CCR87506(c)(1)

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Resident Records
(c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing ...records and for safeguarding the confidentiality of their contents...
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Facility staff agreed to put a lock on the cabinets by POC due date.
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This requirement was not met as evidenced by:
LPAs observed records being stored in cabinets without being locked. This poses a potential personal rights violation to 2 of 2 redients 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 09/03/2026 01:13 PM - It Cannot Be Edited


Created By: Angelica Boyles On 09/03/2026 at 12:08 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NEW WORLD VILLA SOUTH
FACILITY NUMBER: 374604820

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2026
Section Cited
CCR
87465(h)(5)

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Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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Facility staff agreed to stop pre-dispensing medications and staff will complete medication training by POC due date.
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This requirement was not met as evidenced by:
LPAs observed medications being stored in weekly medication dispenser. This poses a potential health and safety risk to 2 of 2 residents in care.
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Type B
09/14/2026
Section Cited
CCR87465(i)

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Incidental Medical and Dental Care(i) Prescription medications which are not taken with the resident upon termination of services...nor disposed of according to the hospice’s established procedures...shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years...
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Facility staff agreed to complete a destruction record of R1's medication by POC due date.
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This requiement was not met as evidenced by:
LPAs observed medication being centrally stored from R1, who passed away on 8/31/26.
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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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 09/03/2026 01:13 PM - It Cannot Be Edited


Created By: Angelica Boyles On 09/03/2026 at 12:20 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NEW WORLD VILLA SOUTH
FACILITY NUMBER: 374604820

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2026
Section Cited
CCR
87412(a)(11)

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Personnel Records (a) The licensee shall ensure that personnel records are maintained on...each employee. Each personnel record shall contain the following information: (11)A health screening...
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Facility staff agreed that S1 would have a completed Health Screening report by POC due date.
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This requirement was not met as evidenced by:
Per records reviewed, S1 did not have a Health Screening form on file. This poses a potential health and safety risk to 2 of 2 residents in care.
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Type B
09/14/2026
Section Cited
CCR87412(a)(13)(A)

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Personnel Records (a) The licensee shall ensure that personnel records are maintained on...each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted... (A) A signed statement regarding their criminal record history...
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Facility staff agreed to have S2 complete a LIC508 Criminal Record Statement by POC due date.
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This requirement was not met as evidenced by:
Per records reviewed, S2 did not have a signed Criminal Record Statement. This poses a potential health and safety risk to 2 of 2 residents 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 09/03/2026 01:13 PM - It Cannot Be Edited


Created By: Angelica Boyles On 09/03/2026 at 12:28 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NEW WORLD VILLA SOUTH
FACILITY NUMBER: 374604820

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2026
Section Cited
CCR
87411(c)(1)

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Personnel Requirements – General (c) All RCFE staff who assist residents...shall receive ...annual training as specified... (1)Staff providing care shall receive appropriate training in first aid from persons qualified...
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Facility staff agreed to have S2 and S3 complete updated first aid training by POC due date.
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This requirement was not met as evidenced by:
Per records reviewed, S2 and S3 did not have up to date first aid training. This poses a potential health and safety risk to 2 of 2 residents 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
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