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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850693
Report Date: 06/01/2026
Date Signed: 06/17/2026 12:31:49 PM

Document Has Been Signed on 06/17/2026 12:31 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:VERNA'S CARE HOMEFACILITY NUMBER:
565850693
ADMINISTRATOR/
DIRECTOR:		STEVENS, EVELYNFACILITY TYPE:
740
ADDRESS:1347 SKEEL DR.TELEPHONE:
(805) 419-4925
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 3DATE:
06/01/2026
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Evelyn StevensTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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At 9:50 A.M. Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced Post-Licensing Inspection of the above-listed facility. Upon arrival LPA met with Licensee, Evelyn Stevens. Entrance interview conducted.

An updated Fire Clearance was approved on 03/10/2026, for a total of five (5) non-ambulatory residents and one (1) bedridden resident. Furthermore, the licensee was granted a hospice waiver for six (6) residents. LPA Conway provided an updated license. Licensee replaced facility license and surrendered their original license.

At 10:15 A.M. a tour of the physical plant was conducted. This facility doesn’t have a staff room; facility will provide 24/7 care. Fire extinguisher was observed to be fully charged and last purchased on 02/04/2026. Between 11:01 A.M. 11:06 A.M., hardwired smoke detectors and a separate carbon monoxide detector were tested and were functional at the time of the visit. Facility is equipped with a fire door to enhance safety and prevent the spread of fire, and it was operable during today’s visit.

Bedrooms: The facility has two (2) single bedrooms and two (2) shared bedrooms designated for residents use only. All bedrooms were furnished appropriately with clean linen, appropriate furnishings and sufficient lighting. No resident bedroom will be used as a public or general passageway to another room, bath, or toilet. There were no visible hazards or discrepancies observed.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2026
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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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: VERNA'S CARE HOME
FACILITY NUMBER: 565850693
VISIT DATE: 06/01/2026
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Continued from LIC 809
Bathrooms: There are five (5) bathrooms. Each bedroom has its own bathroom and there is one (1) shared bathroom for visitors and staff. LPA observed grab bars for each toilet, and shower used by residents. All bathrooms were supplied with appropriate paper and hygiene products. The water temperature was measured in residents’ bathrooms and initially measured outside the required range; water heater temperature was adjusted during the visit. Technical Violation (TV) issued.

Common Areas: These include the Family Room and Dining Room. The common areas were furnished to accommodate a maximum capacity of six (6) residents. Floor surfaces were clean and in good repair. The facility does not have a fireplace. Cameras are installed in common areas; according to the licensee, the cameras do not record audio. The LPA observed nightlights installed in all hallways and passageways. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a temperature of 74 degrees. LPA observed all required posters. Office Room: LPA observed a desk and file cabinets. Staff and resident files will be stored in this room and maintained in a locked manner to ensure confidentiality.

Kitchen: The kitchen appeared clean. There was a sufficient supply of perishable and non-perishable food. LPA conducted a review of expiration dates on product labels. Appliances appear to function properly. Knives are stored locked in a kitchen drawer. At 11:10 A.M. hot water measured 121.6 degrees Fahrenheit; water heater temperature was adjusted during the visit. Technical Violation (TV) issued.

Garage/Laundry Area: Inside the garage, the LPA observed a washer and a dryer machine. Staff will assist residents with all laundry needs. Additionally, LPA observed an ample supply of emergency water and dried emergency food at the time of the visit.

Surrounding Grounds: Garden and front yard are easily accessible to residents, and they are sufficient in size, comfortable and appropriately equipped for outdoor use. Backyard: There was a shaded area with proper furniture for outdoor use. LPA observed one (1) self-closing and latching side gate. There is a locked shed in the backyard that holds gardening tools and extra supplies. LPA observed several gardening beds located in the backyard. LPA advised the licensee that if the gardening beds are used to grow vegetables, the produce shall not be served or provided to residents in care. No bodies of water observed.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2026
LIC809 (FAS) - (06/04)
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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VERNA'S CARE HOME
FACILITY NUMBER: 565850693
VISIT DATE: 06/01/2026
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Continued from LIC 809-C

RECORD REVIEW: Between 2:00 P.M. and 3:30 P.M., staff and resident records were reviewed. Facility staff and residents’ files are stored in a locked file cabinet in the office room close to the facility’s entrance. Three (3) resident and three (3) personnel records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. LPA advised licensee to use the Resident Property and Valuables (LIC 621) form to keep inventory of resident’s belongings. LPA emailed licensee a list of all required consent forms to be kept inside residents’ files. Technical Assistance (TA) issued. A written hospice care plan was missing for Resident #1 (R1). Technical Violation (TV) issued. Staff records reviewed were all completed.

MEDICATION REVIEW: Medications are stored in a locked kitchen pantry. There is a complete first aid kit inside a kitchen cabinet. Between 3:10 P.M. and 4:15 P.M., medications for three (3) residents were audited. During the medication review, the LPA observed that the licensee was not utilizing the Centrally Stored Medication and Destruction Record (LIC622). The licensee provided copies of each resident’s Medication Administrator Record (MAR) and explained that the facility was using the MARs in place of the LIC 622. The MARs reviewed contained the required medication information; however, they did not include medication start dates. The LPA explained the purpose of maintaining a completed LIC 622 for centrally stored medications. The licensee acknowledged the requirement and stated that the facility will begin utilizing the LIC 622 effective immediately. Technical Violation (TV) issued. Each resident's medication was observed stored in its originally received container.

Infection Control/Emergency Disaster Planning: The LPA reviewed the facility's infection control plan and the emergency disaster plan. The facility’s policies and procedures as they pertain to infection control and emergency disaster plan are adequate.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2026
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: VERNA'S CARE HOME
FACILITY NUMBER: 565850693
VISIT DATE: 06/01/2026
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Continued from LIC 809-C

During today’s visit, LPA requested the Personnel Report (LIC500), the resident’s rooster (LIC9020), liability insurance and last emergency drill conducted. During today’s visit, the LPA requested documentation of the facility’s most recent emergency drill. The licensee stated that an evacuation drill had been conducted recently; however, no documentation was available to verify the drill. The LPA informed the Licensee that emergency drills should be conducted quarterly, documented and maintained on file. Documentation should include the date of the drill, the names of all staff who participated, and a summary of the training topic or drill conducted. Technical Violation (TV) issued.

The LPA provided the licensee with the Technical Support Program’s (TSP) information. This is a non-enforcement program offered by the Community Care Licensing Division (CCLD) that provides services and resources to assist providers in meeting licensing requirements. The TSP is designed to help facilities achieve and sustain compliance through training, support, and access to relevant tools.

LPA provided the ED with the following contact information for TSP services. TSP email address TechnicalSupportProgram@dss.ca.gov and their phone number (916) 654-1549. Additionally, LPA advised the ED to review the Provider Information Notices (PINs) on CCLD's website (www.ccld.ca.gov) for further guidance and updates.

Exit interview conducted. A copy of the Licensing Report was issued. No citations issued.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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