Mom's Place 3

Type of visit: Case Management - Other

Licensing Program Analysts (LPA) Valeria Conway conducted an unannounced annual visit to the facility above. At 10:30 A.M., the LPA contacted facility representative, Laila Landu Kulungu, via telephone. Facility representative stated that Licensee, Joseph Jose has decided to close the facility. Upon arrival, LPA observed a real estate sign posted on the front lawn and noted that no vehicles were parked outside or inside the property. At approximately 11:25 A.M. LPA gained entry to the facility and observed that no residents were present. The facility contained no furniture and appeared staged for an open house. LPA did not observe any indications that care and supervision were being provided. The physical copy od the facility license was surrendered to the LPA during today’s visit. As of 12/10/2025, facility# 565850347, MOM'S PLACE 3, located at 975 VALLEY VISTA DR. Camarillo, CA. 93010 is closed. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 10, 2025

Allegation investigated: Staff did not refund overpaid rent Resident sustained unexplained injury while in care

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:10 A.M. The LPA was greeted by Caregiver Kazim Albert. LPA informed the reason for the visit. Caregiver contacted the facility representative by phone, Laila Kulungu. At 10:35 A.M. facility representative arrived. At 10:37 A.M. Administrator, Yusuf Ibironke, was contacted by phone and informed of LPA’s visit. Administrator was unavailable during today's visit. Administrator stated that she not able come to the facility often due to distance, but authorized facility representative, to sign today's reports. Reason for the visit was stated. Entrance interview conducted. During today's visit LPA and staff 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. At the time of the visit, no residents were observed. Continued on LIC 9099-C Substantiated Continued from LIC 9099 LPA Conway conducted an initial complaint visit on 08/27/2024. During that visit, LPA conducted a tour of the physical plant, obtained copy of the resident and staff roster and obtained pertinent information relevant to the investigation. LPA also conducted staff interviews at 11:05 A.M, and 1:15 P.M. At 12:53 P.M., LPA interviewed Administrator via phone.Furthermore, LPA interviewed Reporting Party (RP) on 08/26/2024, 09/17/2024 and on 09/19/2024. Throughout the course of the investigation, LPA reviewed all documents obtained and conducted telephonic interviews with additional credible witnesses and other relevant parties. The following was then determined: The complaint alleges that staff did not refund overpaid rent, as there was an unauthorized electronic money transfer from Resident #1 (R1) account after they had moved out of the facility. During the investigation, it was confirmed that on 07/01/2024, an unauthorized electronic money transfer of twenty-four hundred dollars ($2,400) was deducted from Resident’s #1 (R1’s) account by the facility, despite R1 being moved out and their personal belongings removed at the end of 06/2024. The resident’s responsible party (RP) explained that the electronic transfer of money occurred before auto-pay was canceled. Furthermore, the RP stated that on 06/12/2024, a verbal 30-day move-out notice was given to the facility representative. It was mutually agreed that the final payment of $2400 along with the remaining credit of $4122.56 covering June’s rent, would constitute the last payment for R1’s rental obligation. However, an additional $2400 payment was deducted on 07/01/2024 in error by the facility. A billing reconciliation document provided by the facility indicated that the $2400 deduction was applied toward an outstanding balance owed by R1. LPA reviewed records from both the facility and the RP confirming that a $2400 deduction was made on 07/01/2024 from R1’s account. Both the RP and the facility representative confirmed that R1 had moved out and all belongings were removed by the end of 06/2024. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that R1 was charged for rent after R1 moved out the facility. Therefore, the above allegation Staff did not refund overpaid rent” is deemed SUBSTANTIATED at this time. Continued on LIC 9099-C Continued from LIC 9099-C Regarding allegation “Resident sustained unexplained injury while in care” It was alleged that R1’s thumb got infected and no one in the facility knew what happened to it. Interview with RP revealed that facility staff was not aware on how R1’s thumb became infected. On 05/15/2024, RP took R1 to urgent care, where antibiotics and an antifungal cream were prescribed. On 08/17/2024, a picture of the infected thumb was provided to Community Care Licensing (CCL). Interviews with facility staff indicated that they recalled seeing an issue with R1’s thumb in May 2024; however, the exact date was unknown. Staff stated that this information was relayed to the Administrator, however, this particular change in condition was not formally documented. The Administrator confirmed that they were unaware of how the infection occurred, but stated that staff took R1 to the podiatrist on 06/03/2024 for a follow-up appointment, where additional antifungal cream was prescribed. The facility was unable to provide a doctor’s visit summary for this appointment. LPA was unable to find daily care notes, unusual incident reports submitted by the facility to CCL and/or any doctor visit summaries in the months of May and June of 2024. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation that “Resident sustained unexplained injury while in care”, therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided. Continued on LIC 9099-C LPA Conway conducted an initial complaint visit on 08/27/2024. During that visit, LPA conducted a tour of the physical plant, obtained copy of the resident and staff roster and obtained pertinent information relevant to the investigation. LPA also conducted staff interviews at 11:05 A.M, and 1:15 P.M. At 12:53 P.M., LPA interviewed Administrator via phone. Furthermore, LPA interviewed Reporting Party (RP) on 08/26/2024, 09/17/2024 and on 09/19/2024. Throughout the course of the investigation, LPA reviewed all documents obtained and conducted telephonic interviews with additional credible witnesses and other relevant parties. The following was then determined: The complaint alleges that Resident 1 (R1), a dementia resident, walked out of the facility unnoticed through an unlocked door and was later found on the ground in the driveway by staff. During an interview with R1’s responsible person (RP), it was stated that R1 was found on the ground outside the facility. According to the RP, an ambulance was called, and R1 was transported to the hospital, where a CT scan was conducted. Upon request for documentation supporting these events, the RP was unable to produce any records. A review of R1’s service plan dated on 11/14/2023, states under background information, that R1 is “looking for escape all day” and has wandering and sundowning behavior. However, LPA did not observe documentation of a recent hospital visit or records related to this alleged incident. Additionally, During the initial visit, LPA observed that the main gate leading to the street and garage door were opened. During the plant tour, LPA observed two (2) non-ambulatory residents lying in bed. Interviews with facility staff indicated that, to the best of their knowledge, this incident did not occur. The facility representative also denied that R1 left the facility without staff noticing. Based on the information obtained during the investigation, and despite the information on R1’s documents and the RP statement, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Resident wandered away from the facility due to lack of care or supervision from staff" is deemed UNSUBSTANTIATED at this time. Exit interview conducted/No citations issues/ A copy of report was provided.the state’s words, verbatim · CDSS document, Apr 16, 2025 · control 29-AS-20240823160942

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Apr 16, 2025

Health&Safety§1569.652(c)A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be...resident’s estate, within 15 days after the personal property is removed.This requirement is not met as evidenced by Based on interview and record review, the Licensee did not comply with the above cited section, as R1 moved out and all belongings were removed as of 07/01/2024 and a partial payment was collected by licensee on 07/01/2024 which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 16, 2025

Plan of correction: On 09/20/2024, RP emailed LPA to confirm they had received a check for the amount of twenty-four hundred dollars ($2,400) from the facility owner, covering the refund due.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Apr 18, 2025

CCR 87466 The licensee shall ensure that residents are regularly observed for changes...the licensee shall ensure that such changes are documented & ... the resident's physician and the resident's responsible person. This requirement is not met as evidenced by: Based on interview and record review, the facility did not comply with the above cited section, as R1 sustained an unexplained injury on their thumb while in care, which posed a potential health risk to residentthe state’s words, verbatim · CDSS document, Apr 16, 2025

Plan of correction: Administrator and facility representative agreed to review regulation CCR 87466 and write a statement of understanding to ensure compliance with regulatory requirements. Administrator will submit proof to CCLD no later than POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced CASE MANAGEMENT- DEFICIENCIES visit to this facility and met with, Laila Landu Kulungu - facility representative. The case management visit is being conducted due to deficiencies observed during the investigation of complaint control # 29-AS-20240823160942. The Administrator was unable to sigh the report at the time it was delivered but has designated facility representative to sign on their behalf. During the complaint investigation, the following deficiency was observed: On 8/27/2024, during the initial visit, LPA conducted a review of both current and former residents’ records. The review revealed missing required signatures from residents and/or their responsible parties on key documents. Resident’s #1 (R1’s) file contained a preplacement appraisal information dated on 04/06/2023, and appraisal/needs and service plan form dated on 03/30/2023 and on 11/14/2023, all of which were missing the necessary signatures. Resident’s #2 (R2’s) appraisal/needs and service plan dated on 11/14/2023 lacked the required signatures. Additionally, Resident #3 (R3) needs and service plan dated on 1/18/2022 was also missing the required signatures. During an interview, the facility administrator stated they were unaware of the missing signatures. It was noted that the facility representative is responsible for ensuring that all documentation is complete and kept up to date. The facility representative indicated that documents requiring signatures were typically left for family members to sign during their visits before being filed. However, they were uncertain as to why these particular documents had been filed without the necessary signatures. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies was cited (refer to LIC 809-Ds): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 16, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b) · Plan of correction due date: Apr 18, 2025

87506 Resident Records (b) Each resident’s record shall contain at least the following information: This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as resident files reviewed were missing required signatures on required documents which poses a potential safety and personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Apr 16, 2025

Plan of correction: Administrator and facility representative agreed to review regulation CCR 87506 and write a statement of understanding to ensure compliance with regulatory requirements. Administrator will submit proof to CCLD no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the facility appeared vacant. LPA contacted the Back-up Administrator, Laila Kulungu via telephone and at this time, the reason for the visit was explained. Back-up Administrator stated that staff Howard Suanes will be present during today's visit and gave authorization to sign today's report. Licensee was unable to come during today's visit. At 11:00 A.M. The LPA met with staff Howard Suanes. Reason for the visit was explained. LPA was informed by Back-up Administrator and staff that currently the facility is going to be renovated. Entrance interview. LPA and staff 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. At the time of the visit, no residents were observed. The licensee is preparing to remodel this facility. LPA did not observed any any structural change/addition or renovation being done at the moment. The staff stated the facility currently has no residents as the facility is undergoing a remodel. At 11:15 A.M., smoke and carbon monoxide detectors were tested and operational at the time of the visit. Back-up Administrator stated the facility will retain their license but will not admit residents until the property has been fully remodeled and all safety checks have been completed. Back-up Administrator agreed to inform the licensing department when all work is completed, and facility will resume with admissions. Exit interview conducted. Report was reviewed and issued.the state’s words, verbatim · CDSS document, Dec 18, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced CASE MANAGEMENT- DEFICIENCIES visit to this facility and met with, Laila Landu Kulungu - facility representative. The case management visit is being conducted due to deficiencies observed during the investigation of complaint control # 29-AS-20240823160942. Based on observations, interviews and file review, LPA discovered the Licensee did not submit a written death report for Resident 1 (R1) and an incident report for Resident 2 (R2). At 10:45 A.M., LPA interviewed facility Staff #1 (S1) who stated that R1 passed away a couple of months ago. In May 2024, R2 was taken to the hospital for a thumb infection while in care. After reviewing resident's folders and the facility's e-file under Community Care Licensing (CCL) Regional Office (RO), LPA discovered that since licensure, facility has not submitted any incident reports nor death reports to CCL. LPA advised that within seven days (7) of a death, a written report shall be submitted to Community Care Licensing (CCL). Administrator did not notify CCL within the required time frames. Interviews with facility representative and administrator reflected that facility administrator does not come to the facility often due to distance. Administrator stated that she visits the facility once in a while. Additionally, it was revealed that the facility representative acts as the facility administrator and is the administrator for all of the sister facilities located in Thousand Oaks and Camarillo. Continues on LIC 809-C Continued from LIC 809 Moreover, LPA reviewed two (2) files for Resident #3 (R3) and Resident #4 (R4). Both residents living at the facility at the time of the visit are diagnosed with dementia. Their Physician's reports were complete more than a year ago. LPA explained that licensees who accept and retain residents with dementia shall have this assessment done annually which shall include a reassessment of the resident’s dementia care needs. Both administrator and the facility representative were not able to be present during the LPA's entire visit today. Administrator designated staff Howard Suanes to sign and receive report. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies and civil penalties were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Aug 27, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Sep 10, 2024

87705 Care of Persons with Dementia. (c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment... include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by: Based on resident records review the licensee did not comply with the section cited above as R1 and R2's physician's reprot was not done annually which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2024

Plan of correction: Licensee will submit physician's report for R3 and R4 before POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Sep 10, 2024

87405 Administrator (a) All facilities shall have a qualified and currently certified administrator...The administrator... shall be on the premises a sufficient number of hours to permit adequate attention... specified in this section. This requirement is not met as evidenced by: Based on interviews with staff, the licensee did not comply with the above cited section, as there was no qualified administrator running the facility for several days due to distance, which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 27, 2024

Plan of correction: Licensee will write a statement of understanding regarding regulation 87405(a). Licensee will make sure that administrator is at the facility at least 20 hrs. a week or find a replacement before POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Sep 10, 2024

87211(a)(1) Reporting Requirements - (1) A written report shall be submitted to the licensing agency and to the person responsible... if any; and disposition of the case. This requirement was not met as evidenced by: Based on information gathered during the investigation the licensee did not comply with the section cited as CCL was not notified of an incident that happened to R2 while in care and a death report from 2 months ago. This poses as a potential health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2024

Plan of correction: Licensee will write a statement of understanding on regards Reporting requirements and submit R2's incident report to CCL before POC due date.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing visit to this property at 10:10AM. LPA met with applicant representative Joseph Jose and Administrator Yousuf Ibironke. This application is for a Change of Ownership Application (CHOW) and the current licensed facility has residents in care. The applicant has obtained fire clearance for four (4) bedridden, one (1) ambulatory, and one (1) non-ambulatory with a total capacity of six (6) residents. The proposed facility has a pending Dementia care plan and a pending hospice care waiver for six (6) residents. Applicant completed component II interview on 10/03/2023. During today's visit, Administrator completed component III with the LPA. Beginning at 10:39AM, LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired combination smoke alarm and carbon monoxide detectors were tested and function properly at this time. Sprinkler system was tested during the fire inspection and functioned properly. Fire extinguisher was observed to be fully charged and purchased on 11/16/2023. Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The two (2) common living and dining areas are clean and properly furnished. Properly screened fireplaces were observed in each of the living rooms. A working telephone is present. The proposed facility has six (6) bedrooms total, of which four (4) are private rooms, one (1) is a shared resident room and one (1) is designated as a staff room. All resident bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have appropriate linens. There is also an ample supply of linen, towels and paper products. The proposed facility has three (3) bathrooms, two (2) are for shared resident use and one (1) is a private resident restroom. LPA observed night-lights were present in the hallways. While hot water in one (1) shared restroom and in the kitchen initially measured high, water temperature was adjusted during the visit and measured within the appropriate range in all common sinks prior to the end of today's visit. Report Continued on LIC 809-C The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present, as well as, a seven-day supply of emergency water. Knives were stored in a locked drawer and cleaning supplies are stored in a locked entryway closet. The facility contains a laundry area, containing locked cabinets for chemical storage. A locked medication cabinet was observed, as well as a locked cabinet designated for record storage. First aid kit was observed and was complete. Building and grounds were observed. Patio area contains a shaded seating area for resident use. A detached garage was observed to be locked and inaccessible to residents. Outdoor exit gate was observed to be self-closing and self-latching at this time. All passageways were observed to be clear of hazards. 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 and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 28, 2023