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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881213
Report Date: 03/21/2022
Date Signed: 03/21/2022 11:27:13 AM

Document Has Been Signed on 03/21/2022 11:27 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:OAKWOOD CAREFACILITY NUMBER:
361881213
ADMINISTRATOR:MATA, ERICAFACILITY TYPE:
735
ADDRESS:11137 OAKWOOD AVETELEPHONE:
(323) 494-2602
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 3CENSUS: 0DATE:
03/21/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator-Valencia Johnson TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. An initial application to operate was submitted to the Central Applications Unit (CAU) on 07/12/2021. Fire Clearance was granted 09/28/2021. LPA Allen observed the following:

Structure: Facility was a single-story house with three (3) resident bedrooms, 2 bathrooms, living room, dining area, and kitchen area.

Bedrooms: All bedrooms were adequately furnished with mattress, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm.

Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured by LPA at 114 F.

Kitchen: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals. All cleaning supplies and knives/sharp instruments have an allocated location in a locked closet at the main entrance

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: OAKWOOD CARE
FACILITY NUMBER: 361881213
VISIT DATE: 03/21/2022
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Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.

Yards/Outside: The backyard has a patio section with a with table/seating with umbrella for shade. There were no obstructions. There were no bodies of water observed anywhere on the property.

Garage/laundry/leisure: Laundry area has a washer and dryer available. Garage was organized and free of obstructions.

Emergency Phone Numbers and Exit Plan: Let-Us-No poster and clients rights are posted.

General items: Smoke/carbon monoxide detectors were tested and operational. Fire extinguishers are up to date. LPA Allen tested facility phone and it was verified to be operational.

This facility physical plant is prepared for licensure at this time. This report was reviewed with Valencia Johnson and a copy was provided to the applicant.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC809 (FAS) - (06/04)
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