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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801134
Report Date: 12/15/2023
Date Signed: 12/15/2023 01:29:46 PM

Document Has Been Signed on 12/15/2023 01:29 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:OCEANVIEW WORKSHOP & RECREATION CENTERFACILITY NUMBER:
565801134
ADMINISTRATOR:SARAH ARMSTRONGFACILITY TYPE:
775
ADDRESS:575 EAST SURFSIDE DRIVETELEPHONE:
(805) 986-4818
CITY:PORT HUENEMESTATE: CAZIP CODE:
93041
CAPACITY: 150CENSUS: 59DATE:
12/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Sarah ArmstrongTIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management visit regarding a self-reported incident that occurred on 11/6/2023. LPA was joined by Tri-Counties Regional Center (TCRC) BCBA Quality Assurance Specialist (QAS) Stephanie Cole and TCRC QAS Katy Robison.

On 11/6/2023 at approximately 9:00 a.m., Client 1 (C1) had an incident while using the restroom. Staff 1 (S1) was C1's assigned one to one (1:1) staff. S1 helped C1 into the restroom stall and assisted C1 in removing clothing to use the restroom. S1 then exited the stall to give C1 privacy. S1 then heard noise in the stall and found C1 banging their head on the railing. S1 attempted to block C1 from hitting their head and C1 then started self injurious behaviors to their groin. S1 attempted to block C1 from injuring their groin and C1 tried to bite S1. C1 then stood up from the toilet and that is when S1 saw C1 was bleeding from their groin and had an injury which required immediate attention. S1 called for the lead staff (S2) who came to assist. S2 asked a secretary to call 9-1-1 while S2, the administrator and activity director attempted first aid to stop the bleeding. C1 was sent to the hospital and was accompanied by S2 in the hospital until the administrator from C1's home arrived. Interviews with staff were conducted between 11:04 a.m. and 12:30 p.m. Records were reviewed at approximately 12:00 p.m. The staff schedule appears to be in proper ratio for the clients served the day of the incident. The most recent needs and services plan for C1 dated 4/17/2023, does not address C1's issues with self injurious behaviors specifically in the restroom. During interviews with staff it was stated that C1 would "spend all day in the bathroom" if he could presumably because they have access to their body. There was some confusion among staff about balancing privacy with the level of supervision needed when C1 uses the bathroom.
Based on interviews and record review, C1's needs and services plan requires an update to address the supervision level when C1 uses the restroom and staff need training regarding the update. The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2023
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 12/15/2023 01:29 PM - It Cannot Be Edited


Created By: Teresa Camara On 12/15/2023 at 01:05 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OCEANVIEW WORKSHOP & RECREATION CENTER
FACILITY NUMBER: 565801134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2023
Section Cited
CCR
82068.3(a)

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82068.3 Modifications to Needs and Services Plan. (a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary, but at least annually, to ensure
its accuracy, and to document significant occurrences that result in changes in the
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The administrator will update C1's needs and services plan and train staff on supervision protocols for C1 when in the restroom. The new needs and services plan and staff training log will be provided to CCL on or before 12/22/2023.
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client's physical, mental, psychological, and/or social functioning. This requirement is not met as evidenced by: Based on interviews and record review, C1's needs and services plan does not address C1's need for closer supervision while using the restroom, which is a potential health risk to clients in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023


LIC809 (FAS) - (06/04)
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