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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800022
Report Date: 11/12/2024
Date Signed: 11/12/2024 04:46:43 PM

Document Has Been Signed on 11/12/2024 04:46 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CASA PACIFICAFACILITY NUMBER:
565800022
ADMINISTRATOR/
DIRECTOR:		THERESA PLANTEFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 40CENSUS: 22DATE:
11/12/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:52 AM
MET WITH:Regional Director (S1)TIME VISIT/
INSPECTION COMPLETED:
01:48 PM
NARRATIVE
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On 11/12/2024 at 11:52 AM, Licensing Program Analyst (LPA) Christine Wilson made an unannounced visit to Casa Pacifica Group Home for the purpose of concluding the Required 2- Year inspection. LPA Wilson met with Staff#1(S1), who granted access to the facility and an inspection of the facility client records conducted together. Individuals mentioned in this report are identified on the Confidential Names List (LIC811) dated 11/12/24

LPA Wilson Inspected the Following:
Clients Records Review: LPA Wilson Clients Records Review: LPA and (S1) together reviewed three (3) client records (C1, C2 and C3) which meet qualification.LPA reviewed consent forms, completed by the child's authorized representative(s), to permit the facility to authorize medical care. LPA review copy psychotropic medication log. Record of client list of personal property. The , Admission Agreement t, Health History, and Personal Rights. LPA
observed the child’s Treatment Plan; (All records filed in Avatar).
Children are accompanied to outside extracurricular activities and social events and alternate activities have
been implemented.
A Type B was observed and cited at this time (see LIC809D).
Exit interview was conducted with (S1) and a copy of this report will be emailed to the facility.
SUPERVISORS NAME: Kevin C Sauk
LICENSING EVALUATOR NAME: Christine Wilson
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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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Document Has Been Signed on 11/12/2024 04:46 PM - It Cannot Be Edited


Created By: Christine Wilson On 11/12/2024 at 04:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA PACIFICA
FACILITY NUMBER: 565800022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments:
Client records shall include (1) The results of an examinaion for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above In (2) out of (3) client records inspected there was no record of examination or results of tuberculosiswhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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The licensee will ensure that all group home clients admitted will have evidence of examination or results of tuberculosis screening.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kevin C Sauk
LICENSING EVALUATOR NAME:Christine Wilson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


LIC809 (FAS) - (06/04)
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