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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610497
Report Date: 04/05/2024
Date Signed: 04/05/2024 01:13:03 PM

Document Has Been Signed on 04/05/2024 01:13 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 TREATMENT - PORTSHEADFACILITY NUMBER:
197610497
ADMINISTRATOR/
DIRECTOR:		FLINN, DIANEFACILITY TYPE:
772
ADDRESS:6766 PORTSHEAD ROADTELEPHONE:
(805) 912-6363
CITY:MALIBUSTATE: CAZIP CODE:
90265
CAPACITY: 6CENSUS: 5DATE:
04/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Diane Flinn, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Angela Panushkina conducted a Pre-Licensing Inspection and met with the Administrator, Diane Flin. This is a Change of Ownership Application from facility # 197610461 to # 197610497. An Application to operate a Social Rehabilitation Facility, Short-Term Crisis Residential Treatment Program was received by Community Care Licensing (CCL). A fire clearance was approved on 03/22/24 for a maximum capacity of six (6) ambulatory adults.

A tour of the physical plant was initiated at 10:40am. The facility site consists of a two (2) story single family home. A tour of the physical plant was conducted and the following observed:

KITCHEN: There were sufficient supplies of both cook ware and dining ware as well as nonperishable food (2 days) and perishable food (7 days) to accommodate a maximum capacity of six (6) clients. The appliances and fixture appeared clean, sanitary and functional.

BEDROOMS: There are six (6) private bedrooms designated for client use. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space, and four bedrooms have a private bathroom available for clients use. Two (2) private bedrooms, downstair by the kitchen area, have a shared bathroom. The bedrooms were appropriately furnished and had sufficient supplies of bedding and linens.

BATHROOMS: All bathrooms had functional fixtures and were properly supplied. A hot water was tested and measured at 120.00F.

COMMON AREAS: These consist of dining room, living room and a family room. All common rooms were
Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMEND TREATMENT - PORTSHEAD
FACILITY NUMBER: 197610497
VISIT DATE: 04/05/2024
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appropriately furnished to accommodate a maximum capacity of six (6) clients.

LAUNDRY ROOM: The laundry room is located by the kitchen. The washer/dryer appear to be in good condition. LPA observed the room kept locked and inaccessible to clients in care .

GARAGE: The garage will be used as a storage and kept locked and inaccessible to clients in use.

MEDICATION ROOM: The medication room is located by the garage/family room and is kepted locked and inaccessible to clients in care.

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. In the back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There is a swimming pool that is fenced all around with a gate. LPA was informed that the pool is 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. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. The front and back yards are large and have lawns and garden areas.

Component III Orientation with the Administrator was also conducted during the visit.

Pursuant to Title 22, Division 6 Chapter 2, the facility's physical environment appears to be in compliance and ready for licensure. The copy of this report will be provided to CAB.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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