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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850326
Report Date: 09/03/2026
Date Signed: 09/03/2026 04:37:16 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/03/2026 04:37 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 IIFACILITY NUMBER:
565850326
ADMINISTRATOR/
DIRECTOR:		JACKSON, SARAFACILITY TYPE:
740
ADDRESS:52 CAMINO CASTENADATELEPHONE:
(818) 274-1809
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 5DATE:
09/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Sara JacksonTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct the required annual visit at 12:00 P.M. When the LPA arrived, there were two (2) staff members and five (5) residents present. The LPA met with Administrator, Sara Jackson. Entrance interview.

At 12:10 P.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.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food at the time of the visit. All knives were observed to be locked in a kitchen drawer. At 12:15 P.M. hot water measured 115.2 degrees Fahrenheit. LPA observed a fire extinguisher fully charged and recently purchased on 05/08/2026.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) bedrooms in total. Room between kitchen and garage is designated as a staff room.

RESTROOMS: The LPA observed three (3) restrooms in the facility. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and slip-resistance surfaces. Hot water temperature was measured in all three (3) restrooms and was within the required range of 105 - 120 degrees Fahrenheit.

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 5
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 09/03/2026 04:37 PM - It Cannot Be Edited


Created By: Valeria Conway On 09/03/2026 at 01:21 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MALI'S PLACE II
FACILITY NUMBER: 565850326

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2026
Section Cited
CCR
87618(a)(2)

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87618 Oxygen Administration - Gas and Liquid(a) Except as specified in Section 87611(a),... requires the use of oxygen...: (2)If intermittent oxygen administration is performed by an appropriately skilled professional. This requirement is not met as evidenced by…
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Administrator will contact R1's primary physician or home health regarding their oxygen intake. Home health documentation will be submitted to LPA prior to POC date.
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Based on observation and interviews, the licensee did not comply with the section cited above as R1, a dementia individual, is receiving supplemental oxygen without the supervision of a skilled professional which poses an immediate health risk to persons in care.
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Type B
09/18/2026
Section Cited
CCR87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times... for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by…
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Administrator will repair the side gate and send photos to LPA prior to POC due date.
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Based on observation and interviews, the Administrator did not comply with the section cited above as the side metal gate is not self-closing which poses a potential health 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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
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 5
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 II
FACILITY NUMBER: 565850326
VISIT DATE: 09/03/2026
NARRATIVE
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Continued from LIC 809

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. A fireplace was noted and was observed to be adequately screened and inaccessible to residents in care. LPA observed multiple portable air-conditioning units throughout the facility. The Administrator stated that the facility’s main air-conditioning system is currently non-operational and that the necessary parts have been ordered to complete the repairs. During today’s visit, the temperature throughout the facility was comfortable. Facility has a fire door, and during the visit the fire door was closed. At 1:25 P.M. hardwire smoke alarms and a separate carbon monoxide detector were tested and found to be functional at the time of the visit. The LPA observed the required postings in the common area.

OUTDOOR SPACE: The backyard area contains a shaded area with a table and chairs for residents’ use. There was a shaded area with sufficient room for activities. LPA observed that the black metal side gate was pulled out of the drywall, resulting in the door not closing properly. No bodies of water noted at the time of visit.

GARAGE: A locked garage is accessible from the interior and exterior of the building. Inside the garage LPA observed an extra fridge, emergency water, emergency food and extra medical supplies. Here is where the washer and dryer are located. Cleaning supplies and chemicals are safely stored and inaccessible to residents.

RECORDS: Records review began at 12:36 A.M. LPA reviewed five (5) residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order, however, LPA observed that Resident #1 (R1), a dementia individual that is not able to administer their own prescribed medication who is not receiving hospice or home health services, is being administered supplemental oxygen without the supervision of a skilled professional. LPA reviewed four (4) personnel records including the Administrators. All files were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Last emergency drill (Earthquake Drill) was conducted on 07/28/2026.

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 5
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 II
FACILITY NUMBER: 565850326
VISIT DATE: 09/03/2026
NARRATIVE
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Continued from LIC 809-C

MEDICATIONS: Medications review begin at 1:45 P.M., medications are centrally stored and locked in a cabinet under kitchen counter facing the dining room area; medications are labeled and checked for expiration dates. At the time of the visit, medications were properly documented on the Centrally Store Medication log provided by the pharmacy. LPA observed that medication was being pre-popped in advance of administration. During today’s visit LPA informed the licensee and designee that removing medication from their original packaging in advance of administration (pre-popping) is not permitted. Technical Violation (TV) issued. A first aid kit was observed in the hallway cabinet.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were 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)
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