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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801393
Report Date: 09/18/2024
Date Signed: 09/18/2024 03:03:02 PM

Document Has Been Signed on 09/18/2024 03:03 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GONZALES FAMILY HOMEFACILITY NUMBER:
565801393
ADMINISTRATOR/
DIRECTOR:		VENIE G. GONZALESFACILITY TYPE:
735
ADDRESS:4450 BROWNING DRIVETELEPHONE:
(805) 488-2315
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Venie G. Gonzales, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced one-year required inspection at the above-named facility. Upon arrival, there were five residents in care and three staff on duty. One resident was attending a day program at the time of LPA’s arrival. LPA was greeted by Staff 1. LPA explained the purpose of the visit. Administrator Venie Gonzales arrived at approximately 1:00 pm. Co-Administrator Vanessa Garcia arrived at approximately 1:36 pm. Administrator and Co-Administrator shared the facility inspection responsibilities in different capacities.
The facility is an Adult Residential Facility licensed as a home for a capacity of six (6) individuals with developmental and physical disabilities of which two (2) may be non-ambulatory. The facility maintains a service contract with Tri-Counties Regional Center for all six residents.

Entrance Interview Conducted:
The kitchen incudes, microwave, toaster oven, coffee pot, refrigerator, dishwasher, rice cooker, and a stove and oven. LPA observed a sufficient amount of perishables for 2-days and non-perishables for 7-days. The fire extinguisher is located in the kitchen area near the kitchen sink. It was last serviced on 6/12/2024.
The common areas include the living room upon entry and a dining area off the kitchen.
There are four private bedrooms and one shared bedroom. The shared bedroom has a private bathroom for two residents. LPA observed bedrooms to be clean and properly furnished with nightstands, lighting, and dressers.
There is one restroom off the hallway that provides access to all residents. The private bathroom off the shared bedroom (Bedroom 2) is for residents who reside in Bedroom 2 only. Bathrooms were observed to be clean, in good repair, and grab bars were secure.
The LPA toured the physical areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

Please continue to 809-C, Pg2.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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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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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GONZALES FAMILY HOME
FACILITY NUMBER: 565801393
VISIT DATE: 09/18/2024
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Medications are locked and centrally stored in a locked cabinet in the dining room area. At 1:29 PM LPA reviewed medications for three residents. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record. First Aid kit was observed to be complete.
Staff files were reviewed for personnel records, health screenings, trainings, and First Aid/CPR certification. All staff records are up-to-date and trainings are current.
Residents’ records were reviewed for health screenings, admission agreements, appraisals and re-appraisals, medication administration, and cash resources. Residents’ files were complete.
Residents participate at will in activities such as local day programs, outdoor activities including basketball, volleyball, frisbee, catch football, walks in the neighborhood and the military base nearby, and excursions to local eateries, parks, and the beach. Weekend activities often include eating lunch at the beach and local parks.
Disaster drills are conducted monthly.

Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC809 (FAS) - (06/04)
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