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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850545
Report Date: 09/01/2026
Date Signed: 09/01/2026 01:42:55 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/01/2026 01:42 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:KIND CARE SENIOR HOME LLCFACILITY NUMBER:
565850545
ADMINISTRATOR/
DIRECTOR:		YAZBEK, GEORGEFACILITY TYPE:
740
ADDRESS:4810 JUSTIN WAYTELEPHONE:
(805) 857-6945
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 5DATE:
09/01/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:55 AM
MET WITH:George Yazbek & Marilou RojasTIME VISIT/
INSPECTION COMPLETED:
01:52 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 10:55AM. LPA was greeted by faciliy staff. Administrator was contacted via telephone and arrived shortly after the visit began. Entrance interview conducted.

Beginning at 11:00AM, the LPA, along with facility staff Marilou Rojas, 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. The following was observed:

BEDROOMS: The facility consists of four (4) total bedrooms, of which two (2) are single occupancy and two (2) are designated as shared rooms. LPA observed all resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: One (1) restroom is in the hallway, designated for shared resident use and 1 (one) is designated as a private restroom. Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. The sinks had sufficient liquid soap and paper towels. LPA tested the hot water temperature in the shared resident restroom, which measured within the required range.

COMMON SPACES: Living room and dining room furniture was observed to be in good condition. The LPA observed the required postings upon entry. Medications and first aid are located in a locked cabinet in the living area. There is a working telephone on premises. The LPA observed additional clean linens and towels in the hallway closets. The fire extinguisher was observed to be fully charged and was purchased on 01/25/2026. Beginning at 01:08PM, separate carbon monoxide alarm was tested as well as two (2) individual and all hardwired smoke detectors. All systems were functional at the time of the visit.

Report Continued on LIC 809-C

Kristin Heffernan
Kelly Dulek
DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2026
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: KIND CARE SENIOR HOME LLC
FACILITY NUMBER: 565850545
VISIT DATE: 09/01/2026
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GARAGE/OUTDOOR SPACE: The garage contains the laundry area, emergency food and water, as well as storage space. The backyard patio contains a shaded area and is equipped with furniture for resident use. There is a gate on the side of the house designated for an emergency exit. The LPA observed two (2) locked sheds in the backyard.

KITCHEN: The LPA observed the kitchen and dining area. Knives are stored a locked drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

RECORD REVIEW: Beginning at 11:15AM, the LPA conducted a file review for all five (5) residents and for four (4) staff and observed the following: Staff have current first aid and training completed. Resident records were reviewed for but not limited to current medical assessment, TB tests, appraisal needs and service plans, and consent forms. LPA also reviewed hospice care plan and home health plan for applicable residents. All records were in order.

MEDICATION REVIEW: Starting at 12:42PM, the LPA conducted a review of medication and medication documentation with facility staff for two (2) out of five (5) residents and observed that medications were properly documented and appear to be self-administered as prescribed.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's emergency disaster plan and infection control plan. Both documents were observed to be complete and updated annually as required. The facility's policies and procedures related to infection control are adequate. The facility staff are trained on emergency disaster plan and the last emergency drill was conducted on 07/07/2026.

No citations issued. Exit interview conducted. A copy of today's report was provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC809 (FAS) - (06/04)
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