197610497-4-17-2025-31-AS-APAA-DFTSLM-20250417135833

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610497
Report Date: 04/17/2025
Date Signed: 04/17/2025 01:59:44 PM

Document Has Been Signed on 04/17/2025 01:59 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 - PORTSHEAD		FACILITY NUMBER:	197610497
ADMINISTRATOR/ DIRECTOR:	JAYDEN BEVAN		FACILITY TYPE:	772
ADDRESS:	6766 PORTSHEAD ROAD		TELEPHONE:	(805) 912-6363
CITY:	MALIBU	STATE: CA	ZIP CODE:	90265
CAPACITY: 6		CENSUS: 6	DATE:	04/17/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:30 PM
MET WITH:	Jayden Beavan, Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:30 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	At 12:30pm, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. LPA met with the Administrator arrived shortly after, and LPA explained the reason for the visit. 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 two (2) days nonperishable food and seven (7) days perishable food to accommodate a maximum capacity of six (6) clients. The appliances and fixture appeared clean, sanitary and functional. Fire extinguisher was last serviced on 07/02/2024. Bedrooms: There are six (6) private bedrooms designated for client use. All bedrooms are furnished with beds, dressers and required bedding and linens. The bedrooms have sufficient closet space and an appropriate lighting. Bathrooms: Each client bedroom has its own bathroom, except the bedrooms #1 & #2 have a shared bathroom. In addition, the facility has one (1) additional community bathroom that is available for clients and guests use. All bathrooms had functional fixtures and were properly supplied. The hot water delivered in the client bathroom measured at 119.8°F. Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 04/17/2025

NARRATIVE

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Common Areas: These consist of dining room, living rooms and a family room. All common rooms were appropriately furnished to accommodate a maximum capacity of six (6) clients. The facility maintains a comfortable temperature of 73°F.

Laundry Area: The laundry room is located by the kitchen. The washer/dryer appear to be in good condition. Laundry supplies are kept locked and inaccessible to clients in care.

Garage: The garage was converted to an office/staff space. It is used as a storage and kept locked and inaccessible to clients in care.

Medication Room: The medication room is by the TV room and will is kept locked and inaccessible to clients in care.

Outside Areas: 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 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. 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.

Between 1:00pm to 2:00pm, LPA reviewed records of six (6) clients and four (4) staff. Clients and staff records appeared to be complete and updated. Client files contain signed admission agreements and a medical assessment, and all other required documentarians.

LPA collected Certificate of Liability Insurance and LIC500. The annual license fee is paid in full.

No deficiency cited during today's visit.
Exit interview conducted and copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC809 (FAS) - (06/04)

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