197600280-3-4-2025-31-AS-ASEA-DEFTDH-20250304133821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197600280
Report Date: 03/04/2025
Date Signed: 03/04/2025 01:38:31 PM

Document Has Been Signed on 03/04/2025 01:38 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:	OASIS HOME		FACILITY NUMBER:	197600280
ADMINISTRATOR/ DIRECTOR:	VON BUCK, CLIFTON		FACILITY TYPE:	740
ADDRESS:	1003 WEST AVE. H-4		TELEPHONE:	(661) 948-9594
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY: 4		CENSUS: 3	DATE:	03/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Clifton VonBuck- Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:50 PM

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On 3/04/2025 at approximately 10:00 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the caregiver and LPA stated the reason for their visit. Administrator, Clifton VonBuck arrived shortly after to assist with today’s visit.

LPA asked for the census, Staff/Resident Roster, and liability Insurance. LPA conducted a physical plant tour at approximately 11:00 AM and the following was noted:

The facility is a single unit building with four (4) bedrooms and three (3) bathrooms currently occupying three (3) residents. There is a designated staff room with it’s own private bathroom. The facility has an approved fire clearance for four (4) ambulatory residents. The facility is vendor through North Los Angeles Regional Center (NLARC) and is being operated at a Level II Residential Home for the Elderly. Sign in sheet, hand sanitizer, gloves and masks are available.

Common areas: Living room and dining room were observed to be neat, clean, and organized. Both rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 76°F. A fire extinguisher is located in the kitchen and dated 03/18/24. Required postings such as See/Say Something, Facility License, and Rights of Individuals with Developmental Disabilities are located upon entry. A working telephone was observed.

Kitchen: Kitchen observed to be clean and free from pests. Sufficient supplies of seven (7) day nonperishable food and two (2) day perishable foods were observed. Knives, sharps, cleaning solutions and disinfectants observed to be kept in a locked cabinet underneath kitchen sink. Kitchen appliances observed to be working and in proper condition.

Bedrooms: The Residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Extra linens/covers were observed stored in a storage closet located in the hallway’s passageway. (continued on LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

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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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: OASIS HOME	FACILITY NUMBER: 197600280
	VISIT DATE: 03/04/2025

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Bathrooms: Bathrooms were checked for cleanliness and proper operation. Appropriate grab rails and non-slip mats were observed and in proper condition. The hot water temperature was measured within regulations.

Garage: The garage is located outside of the facility and is kept locked. LPA observed additional refrigerators and freezer used to store extra food. The garage is equipped with sufficient supplies of Personal Protective Equipment (PPE) along with extra supplies of cleaning solutions and toiletries. Laundry Room: The laundry room is located inside the facility near the staff room. Laundry appliances observed to be working and in proper condition.

Staff Room: LPA observed staff room locked and inaccessible to residents.

Backyard: The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. No body of water located at the facility.

Medications: Medications were observed stored in a locked box located in the hallway. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer, and First Aid manual.

Smoke detectors and carbon monoxide observed to be working properly and were tested. The Last Fire Drill was conducted on 2/26/25.

Resident/Staff Records: LPA conducted a complete file review of resident records. Resident records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated.

There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was provided to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

LIC809 (FAS) - (06/04)

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