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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600280
Report Date: 12/09/2023
Date Signed: 03/11/2024 10:44:21 AM


Document Has Been Signed on 03/11/2024 10:44 AM - 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:OASIS HOMEFACILITY NUMBER:
197600280
ADMINISTRATOR:VON BUCK, CLIFTONFACILITY TYPE:
740
ADDRESS:1003 WEST AVE. H-4TELEPHONE:
(661) 948-9594
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:4CENSUS: 4DATE:
12/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Faith Kemanzi - StaffTIME COMPLETED:
12:30 PM
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An unannounced Required One (1) year visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA met with staff Faith Kemanzi who called the administrator Clifton Von Buck and explained the reason for the visit. Mr. Von Buck designated Ms. Kemanzi to sign the report. This is a North Los Angeles Regional Center vendored facility Level II.

LPA conducted physical plant tour inside and out at 9:30 AM. During the tour, LPA observed that the facility has four (4) bedrooms and three (3) bathrooms. One bedroom and one bathroom is designated for staff use. The swimming pool is appropriately fenced but has no water in it and locked during visit.

The front main door is the only entrance being utilized at the facility. There is a sign on the front door that everyone entering at the facility must be screened. Screening area is located immediately before entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover.

The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage.

Bedrooms were toured and observed to be clean and appropriately furnished.
Bathrooms were observed to be clean, sanitary and with necessary supplies. Hot water temperature measured at a range of 117.2°F to 118.6°F (continued to LIC 809-C)
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: OASIS HOME
FACILITY NUMBER: 197600280
VISIT DATE: 12/09/2023
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(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was observed to be in good repair and clean during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area is observed to be clean and sanitary. All disinfectants, cleaning solutions and other toxins were observed to be locked in the hallway cabinet near the main entrance. Laundry area is located adjacent to the dining room by the staff room. Laundry detergent, cleaning agents and other toxins are kept in the locked in the cabinet under the kitchen sink.
Food. The facility is observed to have sufficient food supply both perishable and non-perishable for clients. Temperature of facility wall thermostat was set at 74.0°F and observed to be within the required range.
Fire extinguisher was observed to be located in the living room. Fire extinguisher was observed to be operable and last inspected on 03/23/23. Fire alarms are hardwired, tested and observed to be operational. There was a carbon monoxide detector installed in the facility.
Medication were observed to be locked, inaccessible and stored in the cabinet in the bedroom hallway cabinet. There was a complete first aid kit inside the cabinet. Knives are locked in the cabinet under the sink.
Garage is detached to the house and observed to be locked and inaccessible to clients. Garage is also used as frozen emergency food and other supplies storage.
Client records. All four (4) client records were reviewed. Clients record are complete and current.
Staff records were also reviewed. All staff present records were reviewed, they all have criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate was observed to be current.

Disaster drill was last conducted on 11/10/23. Required posting observed in facility (complaint hot line poster, personal rights, etc).

There was no health and safety hazard observed during the day of inspection.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023
LIC809 (FAS) - (06/04)
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