565850366-9-3-2026-29-AS-BBAI-DXKVET-20260903162252

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850366
Report Date: 09/03/2026
Date Signed: 09/03/2026 04:23:43 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/03/2026 04:23 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MAJESTIC RESIDENTIAL CARE		FACILITY NUMBER:	565850366
ADMINISTRATOR/ DIRECTOR:	OSILESI, KEMI		FACILITY TYPE:	740
ADDRESS:	2036 CUTLER ST		TELEPHONE:	(310) 503-2515
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 6		CENSUS: 5	DATE:	09/03/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:28 PM
MET WITH:	Kemi Osilesi		TIME VISIT/ INSPECTION COMPLETED:	04:30 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) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with Administrator Kemi Osilesi and explained the reason for the visit. At approx 12:35 p.m. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. LPA inspected the kitchen/food service area. LPA observed Knives and other sharp objects were stored in a locked drawer to the left of the dishwasher. Cleaning supplies were stored underneath the sink and were inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility maintained a sufficient supply of perishable and non-perishable food, which was properly stored. Medications were stored in a cabinet inaccessible to residents in care. Common area furniture was observed to be in good condition. Two (2) residents were observed watching television in the living room while staff served lunch. Multiple board games and activities were stored on a bookshelf in the living room. A sufficient supply of clean linens and towels was stored in the hallway near Room #3. PPE and toiletries were stored in a closet near Room #1 and were inaccessible to residents in care.The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detectors and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were fully charged and had a purchase date of July 2026. Five (5) resident bedrooms were observed and were appropriately furnished with clean linens, adequate furnishings, and sufficient lighting. Resident restrooms were clean, sanitary, and operational. Restrooms were equipped with grab bars and non-skid surfaces and were sufficiently stocked with necessary supplies and paper towels. Hot water temperatures in each restroom measured between 105 and 120 degrees Fahrenheit. A staff room near the entryway was observed to be empty and inaccessible to residents in care at the time of the visit.

Desaree Perera
Brian Balisi
	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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MAJESTIC RESIDENTIAL CARE	FACILITY NUMBER: 565850366
	VISIT DATE: 09/03/2026

NARRATIVE

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Office area was located next to the dining area. LPA observed facility files stored inaccessible to residents in care. All exits have functioning auditory devices and were operational at the time of the visit. LPA observed required postings on bulletin board by entry way, on bulletin board by garage as well as throughout the home.
An attached garage was observed and was inaccessible to residents in care. The garage contained an additional refrigerator for properly storing perishable food, a laundry area, furniture, medical equipment, PPE, incontinence supplies, and other facility-use items. Several emergency bins were adequately stocked and ready for use during an emergency. Portable power stations and solar panels were also available for emergency use. The backyard included a covered outdoor area with appropriate furniture. Two (2) self-latching gates were observed, and the passageways were clear of obstructions. No bodies of water were observed at the time of the visit.

Records review, five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Six (6) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time .

Medication review, medications for all residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.

Infection control / Emergency Disaster plan: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted in August. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator. Smoke detectors and carbon monoxide detectors were tested, all alarms were functional at the time of the visit.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster and limited liability insurance. Exit interview conducted and copy of the report issued to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
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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