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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604326
Report Date: 10/23/2022
Date Signed: 10/23/2022 04:41:13 PM

Document Has Been Signed on 10/23/2022 04:41 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:OASIS VILLAGE CAREFACILITY NUMBER:
374604326
ADMINISTRATOR:SAHID, RAMLAFACILITY TYPE:
740
ADDRESS:3865 SHIRLENE PLTELEPHONE:
(619) 727-7335
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY: 6CENSUS: 5DATE:
10/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Abdiaziz Hussen, Manager TIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management visit. LPA identified herself and was granted entry by Caregiver Teyba Abdu. LPA met with Abdiaziz Hussen, Manager
and discussed the purpose of the visit.

On October 21, 2022, the facility self reported a resident death regarding Resident 1 (R1) (See LIC 811 Confidential Names List) to Community Care Licensing. This visit was conducted to follow-up with the death report.

During today’s visit, LPA briefly toured the facility, conducted an interview with Abdiaziz Hussen, Manager, requested and obtained relevant records. This case management visit requires further follow-up and a copy of the resident's death certificate was requested upon receipt. No deficiencies were cited during today’s visit.

An exit interview was conducted with Abdiaziz Hussen, Manager, and a copy of this report, LIC 811 and Licensee/Appeal Rights (LIC 9058 01/16) were provided to the Manager at the conclusion of the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2022
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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