197610916-5-29-2026-31-AS-MAGN-DUJRUH-20260529131957

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610916
Report Date: 05/29/2026
Date Signed: 05/29/2026 01:21:07 PM

Document Has Been Signed on 05/29/2026 01:21 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	JADE VILLA CARE HOME		FACILITY NUMBER:	197610916
ADMINISTRATOR/ DIRECTOR:	ROJAS, PAMELA		FACILITY TYPE:	740
ADDRESS:	8413 RHEA AVE		TELEPHONE:	(818) 626-9343
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY: 6		CENSUS: 4	DATE:	05/29/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Pamela Rojas- Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:35 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) Mariana Agban conducted a Pre-Licensing Inspection with Administrator Pamela Rojas and Licensees Romeo Rojas, Jeffery Alvarez and Madeleine Ayllon . A Change in Ownership (CHOW) Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 09/18/2025. A fire clearance was approved on 01/30/26, for two (2) non-ambulatory residents and four (4)bedridden residents, for a total capacity of six. The bedridden fire clearance is for rooms #1#2 and #3. A dementia plan of operation has been submitted. A hospice waiver has been requested for four (4) residents pending the Manager's approval. The smoke alarms and carbon monoxide detector are battery-operated and functional. The fire extinguisher is located in the kitchen with a service date of 05/27/2026. A tour of the physical plant was initiated at approximately 10:00 am and the following was observed: KITCHEN: The facility has a Kitchen area equipped with a refrigerator, microwave oven, and sink. Adequate supplies of perishable and nonperishable food and dining ware accommodated a maximum capacity of six (6). Medications are kept locked in the kitchen cabinets. BEDROOMS: The facility have five (5) bedrooms. Four (4) bedrooms are designated for residents' use. Bedrooms #1, #2, and #3 designated for four (4) bedridden residents. Bedroom#4 is designated for two(2) non ambulatory residents. LPA observed staff room next to the kitchen area. All bedrooms in use by the residents are furnished with beds, nightstands, chairs, dressers, bedding, and linen. The bedrooms have sufficient lighting and closet space. BATHROOMS: The facility has 2.5 bathrooms. There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 108.9 and 107.5 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection (Continue on 809C)

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Mariana Agban
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JADE VILLA CARE HOME	FACILITY NUMBER: 197610916
	VISIT DATE: 05/29/2026

NARRATIVE

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COMMON AREAS: These included the living room and dining room. The living room was equipped with
furniture, a television, tables, and chairs. The dining area has a large dining room table to accommodate six
(6)residents. There is a functioning telephone on the premises in the living room. There is also an office/workstation area in the dining/kitchen area.
LAUNDRY Area/GARAGE:The garage is used as extra storage. Access to the garage is from outside the facility. LPA observed the washer and dryer in good repairs. Laundry detergents will kept
locked and inaccessible to the residents.
Resident Files: LPA conducted a file review of random resident records to ensure compliance with licensing forms.
Staff Files: LPA conducted a file review of the Administrator file to enure compliance with licensing form.
SURROUNDING GROUNDS: The driveway, passageways, and entrance to the home were clear of
obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a patio and backyard furniture to accommodate the six (6) residents. The facility's backyard has sufficient yard space. The gate at the side of the home was checked to ensure no locks were installed, and that exits and passageways were clear for emergency evacuation.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held.
Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to
be compliant and ready for licensure. CAB will be advised and a copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Mariana Agban
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026

LIC809 (FAS) - (06/04)

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