<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610259
Report Date: 09/01/2022
Date Signed: 09/01/2022 11:37:59 AM

Document Has Been Signed on 09/01/2022 11:37 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:DYNAMIC BEHAVIORAL HEALTH, DBA "MONTARE OASIS"FACILITY NUMBER:
197610259
ADMINISTRATOR:DZIOBA, TIFFANYFACILITY TYPE:
772
ADDRESS:5705 SHIRLEY AVETELEPHONE:
(917) 374-4215
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 6CENSUS: 0DATE:
09/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Katarina BoshoffTIME COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Michael Cava conducted an announced Pre Licensing visit to this facility and met with applicant representative Katarina Boshoff . This is an initial application to operate a Social Rehabilitation Facility (SRF). The applicant is Dynamic Behavioral Health LLC. The Fire Clearance was received by the Department on June 22, 2022. Clearance granted for ambulatory only on June 15, 2022.

Purpose of today’s visit is to inspect the facility to ensure that the it is in compliance with the rules and regulations of California Code of Regulations, Title 22.

Facility is a single storey home. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The facility has dual smoke/carbon monoxide alarm system. It is hard wired and interconnected. There are brand new fire extinguishers located in the kitchen and throughout the hallway and common areas of the facility. Dual Smoke and Carbon Monoxide detectors were observed all over the facility. Hot water was tested in the common bathroom and measured at 120 °F. There is a functioning telephone on the premises. There are four (4) resident bedrooms. Two (2) rooms are private, and the other two (2) rooms are shared. Resident bedrooms were observed to be appropriately furnished with adequate lighting. Passageways to enter and exit each rooms were clear of any obstruction. The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room area has plenty of space with a pool table and comfortable furniture. Resident and staff records will be stored, locked and maintained in staff office. There is also a medication room located near the entry of the facility. First aid kits will be stored in staff office and the kitchen. There are three (3) bathrooms in the facility. Non-skid material in place. The master bathroom has a bath tub, which would be optional for client use.

(continued on LIC 809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DYNAMIC BEHAVIORAL HEALTH, DBA "MONTARE OASIS"
FACILITY NUMBER: 197610259
VISIT DATE: 09/01/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The kitchen knives will be stored and locked in a lock box. Kitchen cleaning supplies will be stored in a locked cabinet. Appliances in the kitchen appeared to be functional. The laundry area is located adjacent to the kitchen. Additional cleaning supplies will also be maintained and locked in the laundry area. The garage has an access from inside the house and was observed to be locked and inaccessible. The garage is used for additional storage for for emergency food supplies, tools and unused furniture. The necessary precautions have been made to the facility to safely house the residents such as auditory alarms and locked areas for centrally stored medications. Facility appears to be clean and in good repair.

In addition to inspecting the inside of the facility, the outdoor, front and back yards were also inspected. Sitting areas and outside furniture were observed to be in good repair. Lawn is properly maintained. There is a swimming pool, which has a five foot fence around it's parameters to prevent clients from entry unsupervised. In order to gain access, the fence has a gate which will be locked at all times. There is a smoke pit in the backyard that is non-operational. There is a gym located at the backside of the home. Entry is gained through the backyard. According to the applicant, the gym will only be utilized when supervision is present. There is also a bbq area with a sink, which will also be non-operational. Both front and back yards were observed to be clear of any obstruction.

Both the administrator and applicant representative, Tiffany Dzioba and Katarina Boshoff have taken Component III within the last year. Component III will be waived at this time.

Pursuant to Title 22, the facility is compliant to regulation, and ready for licensure. This report will be forwarded to the Centralized Application Bureau (CAB). The applicant will be notified by the CAB Analyst when their license is approved.

Exit interview conducted and copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2