<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850324
Report Date: 09/03/2026
Date Signed: 09/03/2026 04:46:49 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/03/2026 04:46 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:MALI'S PLACE IFACILITY NUMBER:
565850324
ADMINISTRATOR/
DIRECTOR:		JACKSON, SARAFACILITY TYPE:
740
ADDRESS:68 CAMINO CASTENADATELEPHONE:
(818) 274-1809
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 3DATE:
09/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Sara JacksonTIME VISIT/
INSPECTION COMPLETED:
12:00 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) Valeria Conway arrived at the facility unannounced to conduct the required annual visit at 9:05 A.M. When the LPA arrived, there was one (1) staff member and three (3) residents present. The LPA was greeted by Caregiver, Araceli Camarillo, and informed them the reason for the visit. Caregiver contacted the Administrator by phone, Sara Jackson. At 9:18 A.M., the Administrator arrived at the facility.

At 9:23 A.M., the LPA conducted a tour of the physical plant with the Administrator, to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. This facility doesn’t have a staff room; the facility will provide 24/7 care. The following was observed:

Kitchen: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food as well as emergency food. At 9:45 A.M. hot water temperature measured at 119.8 degrees Fahrenheit.

Bedrooms: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) bedrooms in total; 4 (four) are private bedrooms and one is designated as a shared room. No bedroom was used as a passageway to another room, bath, or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair.

Continued on LIC 809-C

Desaree Perera
Valeria Conway
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)
Page: 1 of 4
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)
Page: 2 of 4
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: MALI'S PLACE I
FACILITY NUMBER: 565850324
VISIT DATE: 09/03/2026
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
26
27
28
29
30
31
32
Continued from LIC 809-C

File review: A review of facility files was initiated at 9:40 A.M. and the following was observed. LPA reviewed three (3) residents files. Files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All records were in order. Additionally, LPA reviewed three (3) staff files including the administrator’s. All documents reviewed appeared complete and current.

Medication review: Began at 1:45 P.M.; medications are centrally stored and locked under the kitchen counter; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. LPA observed that medication was being pre-popped in advance of administration. During today’s visit LPA informed the Administrator that removing medication from their original packaging in advance of administration (pre-popping) is not permitted. Technical Violation (TV) issued. No errors observed during the medication review.

INFECTION CONTROL/EMERGENCY DISASTER: LPA also reviewed the facility's Emergency Disaster Plan and Infection Control Plan. Both plans were observed to be complete and updated annually as required. Last electrical safety drill was conducted on 07/20/26.

During today’s visit LPA obtained a copy of facility’s Employee Record (LIC 500), Resident Roster and Liability Insurance.

Exit interview conducted. No deficiencies issued during today’s visit. A copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
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: 3 of 4
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: MALI'S PLACE I
FACILITY NUMBER: 565850324
VISIT DATE: 09/03/2026
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
26
27
28
29
30
31
32
Continued from LIC 809

Restrooms: The LPA observed four (4) restrooms in the facility; two (2) are shared resident restrooms, one (1) is a private restroom, and one (1) half bath is designated for staff and visitor use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and slip-resistance surfaces. Water temperature was measured in the common resident restrooms and was within the required range.

Common spaces: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, the living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. The facility maintained a temperature of 71 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. The fire extinguishers are fully charged and recently purchased on 05/08/2026. Hardwired combination smoke/carbon monoxide detectors were tested at 10:11 A.M. and were operational at this time. Facility is equipped with a fire door to enhance safety and prevent the spread of fire. During today’s visit, fire door was observed closed.

Outdoor Space: The backyard area contains a shaded area with a table and chairs for resident use. There is a non-functioning fountain, which was observed to be empty at the time of the visit. There were no bodies of water noted. Facility has two total gates; both were observed to be self-closing and self-latching gates with clear passageways for emergency exit use. LPA observed a back house where gardening tools and other supplies are stored.

Garage/Office: The garage is where the washer and dryer are held, including emergency food and emergency water. Cleaning supplies, disinfectants, sharps and knives were observed to be locked in a cabinet in the garage. All cleaning compounds were stored in areas separately from food supplies. There is an office area whit a desk and a phone and files are held.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
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: 4 of 4