The Clubhouse Haven

Type of visit: Required - 1 Year

At 9:55 A.M. Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced annual inspection of the above-listed facility. Upon arrival LPA met with Licensee, Jocelyn Cacal and the reason for the visit was explained. Entrance interview conducted. At 10:00 A.M., LPA along with Licensee conducted a facility plant tour. Fire extinguisher was observed to be fully charged and last purchased on 06/10/2025. At 10:34 A.M. hardwire smoke detectors and carbon monoxide detectors were tested and were functional at the time of the visit. Facility is equipped with two (2) fire doors to enhance safety and prevent the spread of fire. During today’s visit, Licensee stated that a third-party company is scheduled to install magnetic hold devices on each fire door to remain open during business hours. Bedrooms: The facility consists of six (6) private resident bedrooms and one (1) staff room. Auditorial signal system was observed in each door around the facility. 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. Bathrooms: The facility consists of seven (7) bathrooms. Three (3) are shared bathrooms and four (4) are located inside Room #2, # 3, #4 and #5. LPA observed that the hand washing sink located in the shared bathroom across from room #1 did not drain properly while the faucet was running. Technical Violation (TV) issued. During today's visit the sink was fixed. Continued on LIC 809-C Continued from LIC 809 LPA observed all bathrooms to have grab bars and slip-resistant floors and mats. Between 10:14 A.M. and 10:27 A.M. hot water temperatures were measured in all bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit. Common Areas: These include the Foyer, Entertainment Room, Living Room and Dining Room. The common areas were checked for cleanliness and furniture was checked for functionality. At the time of the visit, LPA observed locked cabinets located in the entertainment room designated to store residents’ medications and first aid kit. The facility has a fireplace, at the time of the visit, LPA observed the fireplace properly screened. LPA observed night lights in all hallways and passages. The facility maintained a temperature of 75 degrees Fahrenheit. LPA observed that all required posters were posted. LPA observed a working camera recorder facing the main entrance. Licensee stated that camera does not record sound. 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 10:03 A.M., hot water measured 132.8 degrees Fahrenheit. The LPA did not observe a warning sign posted at the sink. The Licensee stated that residents do not have access to, nor use, the kitchen sink. Technical Violation (TV) issued. Licensee posted a "Hot Water" warning sing on the kitchen window above the kitchen sink. LAUNDRY ROOM: LPA observed a washer and a dryer machine and a sufficient amount of emergency water. Staff will assist residents with all laundry needs. Furthermore, LPA observed several locked cabinets where chemical, hygiene products and cleaning supplies are be stored. Detached Garage and Surrounding Grounds: A detached garage was observed to store extra supplies and gardening tools. The front and back yards are easily accessible to residents, and they are sufficient in size, comfortable and appropriately equipped. There was a shaded area with proper furniture for outdoor use. LPA observed sufficient space to accommodate outdoor activities for residents and an electric self-closing gate. There are no bodies of water on the premises. Continued on LIC 809-C Continued on LIC 809-C RECORD REVIEW: Between 11:55 A.M. and 2:00 P.M., staff and resident records were reviewed. Facility staff and residents’ files are stored in a locked file cabinet in the foyer. Six (6) resident and six (6) 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 appropriate training. All staff files were completed. During the resident record review, the LPA observed that one (1) resident’s Needs and Service Plan was incomplete. Additionally, the LPA observed that (3) out of six (6) resident’s Needs and Services Appraisal were missing either the resident’s signature or the signature of the resident’s responsible person. MEDICATION REVIEW: Medications are locked in cabinets located in the entertainment room. Between 2:10 P.M. and 3:15 P.M., medications for six (6) residents were audited. During the medication audit, the LPA observed that two (2) prescribed medications administered to Resident #1 were not listed on the Centrally Stored Medication and Destruction Record (LIC622) or the Medication Administrator Record (MAR). Record review and medication packages confirmed that the medication had been administered as prescribed. 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. LPA requested a copy of both plans to be filed with the Regional Office. During today’s visit, LPA requested the Personnel Report (LIC500), the resident’s rooster (LIC9020), liability insurance and last emergency drill. Last emergency drill was conducted on 04/18/2026 Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were 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.the state’s words, verbatim · CDSS document, Jun 2, 2026

Type of visit: Prelicensing

At 9:45 A.M. Licensing Program Analyst (LPA) Valeria Conway conducted an announced Pre-Licensing Inspection to the above listed facility. Upon arrival LPA met with Administrator, Jocelyn Cacal. The proposed physical plant is a one (1) story single family dwelling located in a residential neighborhood of Somis, CA. This facility will be housing residents with dementia. There are no client residing in the facility at the moment. Entrance interview conducted. An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 12/09/2024. On 05/06/2025 a Fire Clearance was approved for a maximum capacity of six (6) non-ambulatory residents, including one (1) bedridden resident in Room #5. The facility is equipped with two (2) fire doors to enhance the resident safety and prevent the spread of fire. One (1) fire door separates all resident rooms from the common areas, and the second fire door is installed at the entrance of Room #5 which is designated for a non-ambulatory or a bedridden resident. At the time of the visit, the LPA did not observe a magnet or approved device in place to hold the fire doors open. LPA informed the Administrator that fire doors must not be propped open with door stoppers or any other items that could obstruct their automatic closure in the event of an emergency. The Administrator acknowledged this requirement and stated that both fire doors will remain closed at all times. This pending facility has a dementia care program and a granted hospice waiver for 6 (six) residents. Continued on LIC 809-C Continued from LIC 809 At 10:00 A.M. LPA along with Administrator conducted a facility plant tour for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following observed: Fire extinguishers are fully charged and recently purchased on 06/10/2025. Smoke detectors are hard wired throughout the facility. Fire alarms/carbon monoxide detectors were tested at 11:10 A.M. and were functional at the time of the visit. LPA observed all required postings on the facility wall, a revised Emergency and Disaster Plan and a Plan of Operation is in use. BEDROOMS: The facility consists of six (6) private resident bedrooms and one (1) staff room. There was a model furnished bedroom equipped and supplied with appropriate furniture including but not limited to a bed, a chair, a night stan, a lamp and a chest of drawers, bedding, and linens. No client bedroom will be used as a public or general passageway to another room, bath, or toilet. There were no visible hazards or discrepancies observed. Auditorial signal system was observed in each door around the facility. LPA observed that Rooms #2, #4, #5 and #6 did not have curtains or window coverings on the windows to ensure the privacy of residents occupying the bedroom. Additionally, Room #5 was observed to be missing a curtain or a window covering on the exit door. During today’s visit, rails and curtains were installed. BATHROOMS: The facility consist of seven (7) bathrooms. Three (3) are shared bathrooms and four (4) are located inside Room #2, #3, #4 and #5. LPA observed toilets and handwashing stations to be in operation condition. Solid waste containers are in good repair and have tight-fitting covers. Additionally, LPA observed all bathrooms to have grab bars and slip-resistant floors and mats. Between 10:20 A.M. and 10:40 A.M. hot water temperatures were measured in all bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit. Facility provides each resident privacy and personal accommodations. Continued from LIC 809-C Continued from LIC 809-C COMMON AREAS: These include the Foyer, Entertainment Room, Living Room and Dining Room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. At the time of the visit, LPA observed locked cabinets located in the entertainment room designated to store staff and resident files, residents’ medications and first aid kit. Facility will properly document medication on the Centrally Store Medication and Destruction log. The facility has a fireplace, at the time of the visit, LPA observed the fireplace properly screened. Facility has installed internet service for resident use. Facility has enough space to store clean common linen items such as bed sheets, towels, pillowcases, and mattress pads. LPA observed night lights in all hallways and passages. Facility has an auditory signal system in place at the time of the visit. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. KITCHEN: Appliances and fixtures appeared clean and functional. At the time of the visit, LPA observed a sufficient amount of dining and cookware. LPA observed a sufficient amount of perishable food. Administrator is aware that food supply shall accommodate a maximum capacity of six (6) residents and facility staff for seven (7) days. Sharps and knives will be stored in a locked kitchen drawer located to the left of the dishwasher. There were no visible immediate hazards observed. At 10:45 A.M. hot water temperature measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit. LPA observed a working phone available for resident’s use. LAUNDRY ROOM: LPA observed a washer and a dryer machine and a sufficient amount of emergency water. Furthermore, LPA observed several locked cabinets where chemical, hygiene products and cleaning supplies will be stored. SURROUNDING GROUNDS: Garden and yard are easily accessible to residents, and they are sufficient in size, comfortable and appropriately equipped for outdoor use. There was a shaded area with proper furniture for outdoor use. LPA observed one (1) self-closing and latching side gate. Additionally, LPA observed sufficient space to accommodate outdoor activities for residents. There are no bodies of water on the premises. Continued from LIC 809-C Continued from LIC 809-C GARAGE: LPA observed a detached locked garage, which contains hardware supplies, extra mobility devices and tools. COMPONENT III ORIENTATION: A Component III Orientation was conducted with the Administrator during today's visit. The following needs to be completed/Photos sent to LPA prior to licensure:  No deficiencies noted. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted. A copy of the Licensing Report was issued.the state’s words, verbatim · CDSS document, Jun 16, 2025

Type of visit: Office

COMP II by CAB successfully completed Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 Method: Telephone call with CAB COMP II Participants: Jocelyn Cacal, Administrator/Owner; Shannon Betker, analyst. Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, May 13, 2025