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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610485
Report Date: 03/19/2024
Date Signed: 03/19/2024 01:20:35 PM

Document Has Been Signed on 03/19/2024 01:20 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AMEND TREATMENTFACILITY NUMBER:
197610485
ADMINISTRATOR:FLINN, DIANEFACILITY TYPE:
772
ADDRESS:6758 WILDLIFE ROADTELEPHONE:
(805) 912-6363
CITY:MALIBUSTATE: CAZIP CODE:
90265
CAPACITY: 6CENSUS: 6DATE:
03/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Diane Flinn, Administrator TIME COMPLETED:
01:15 PM
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 Analysts (LPAs) Angela Panushkina and Perchui Milena Khurshudyan conducted a Pre-Licensing Inspection and met with the Administrator, Diane Flin and a Program Director, Shira Rebibo. This is a Change of Ownership Application from facility #197610240 to #197610485. An Application to operate a Social Rehabilitation Facility, Short-Term Crisis Residential Treatment Program was received by Community Care Licensing (CCL) on 03/04/2024. A fire clearance was approved on 12/26/2023 for a maximum capacity of six (6) ambulatory adults.

A tour of the physical plant was initiated at 10:50am and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. The There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). There is a fire extinguisher in the kitchen area and in a hallway were last serviced on 10/30/2023.

BEDROOMS: There are five (5) bedrooms designated for client use. One (1) bedroom will be designated for shared room and the other four (4) bedrooms are private. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space.

BATHROOMS: Each client bedroom has its own bathroom. The bathroom in bedroom #1 is the only client bathroom equipped with a bathtub. It will be made available for clients in that room to utilize. In addition to the four (4) bathrooms located in each client room, facility has two (2) additional community bathrooms that are available for client use. The hot water delivered in the client bathrooms measured at 120°F.

Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2024
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: AMEND TREATMENT
FACILITY NUMBER: 197610485
VISIT DATE: 03/19/2024
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
COMMON AREAS: These included an activity room equipped with physical fitness equipment, living room furniture, a television, tables and chairs and a dining area. The Common areas are furnished with adequate furniture to accommodate a maximum capacity of six. At 12:20pm, smoke and carbon monoxide detectors were tested and observed to be operable. There were no visible immediate hazards.

LAUNDRY ROOM: The laundry room is located in the garage, same area as the activity/exercise room. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

MEDICATION ROOM: The medication will be kept in a locked cabinet located in staff office. First aid kit reviewed for required items and manual.

OFFICE, STAFF AND THERAPY/TREATMENT AREAS, GUEST ROOM: There are multiple office spaces and a guest room that will be used for administrative duties and individual therapy. Group Therapy will be conducted in the common areas.

SURROUNDING GROUNDS: The entrance to the home is gated and requires for guest to be announced. The driveway serves as a large parking lot for guests. There is a tennis/basketball court located at the front of the home. In the back of the facility has sufficient yard space. There is a swimming pool that is fenced all around with a gate that will be kept locked at all times. The fence surrounding the swimming pool is approximately 5 feet high all around. You will need a key to gain entry to the swimming pool as it is kept locked at all times. There is a bridge that leads to a tree house, which is chained, locked and inaccessible to the clients. The lower field has a gate that has a passageway leading to the beach. This gate will remain locked, inaccessible and off limits to clients. The gate at the back is not a direct exit to evacuate from the facility.

Component III was also conducted at 12:00pm.

Pursuant to Title 22, Division 6 Chapter 2, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.
Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2