565801393-9-11-2025-29-AS-QHUH-DLES64-20250911133519

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801393
Report Date: 09/11/2025
Date Signed: 09/11/2025 01:35:40 PM

Document Has Been Signed on 09/11/2025 01:35 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:	GONZALES FAMILY HOME		FACILITY NUMBER:	565801393
ADMINISTRATOR/ DIRECTOR:	VENIE G. GONZALES		FACILITY TYPE:	735
ADDRESS:	4450 BROWNING DRIVE		TELEPHONE:	(805) 488-2315
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 6		CENSUS: 6	DATE:	09/11/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Jeannette Graves - Administrator Ralph Garcia - Staff		TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual inspection. LPA arrived at the facility at 10:30AM, met with Staff Ralph Garcia and explained the purpose of the visit. At 11:08AM, Administrator Jeannette Graves arrived. Entrance interview conducted. LPA Huynh and the Staff conducted a tour of the physical plant at 10:40AM to ensure there were no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The facility is a Tri-Counties Regional Center Level 4 residential home. The following was observed: COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. An office/activity area was located within the dining room and had required postings along the wall and a screened fireplace. Facility files and resident medications were locked and stored in a cabinet in the office area. The facility maintained a comfortable temperature throughout the visit. KITCHEN: Knives were stored inaccessible in a cabinet. Kitchen appliances were in good and operable condition. The facility had enough supply of perishable and non-perishable food. The freezer and refrigerator were stocked with a variety of foods and observed to be of good quality with labels and dates. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GONZALES FAMILY HOME	FACILITY NUMBER: 565801393
	VISIT DATE: 09/11/2025

NARRATIVE

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BEDROOMS/RESTROOMS: The facility had five (5) bedrooms: four (4) private resident rooms and one (1) shared resident room. The shared resident room had a direct exit to the outside. Bedrooms were furnished appropriately with sufficient lighting and an extra supply of bed linens stored in the hallway cabinets. There were two (2) restrooms: one (1) private resident restroom and one (1) shared resident restroom located in the hallway. Resident restrooms were observed to be clean and in good condition with grab bars and non-skid mats available. A sufficient amount of soap and paper products were supplied in each restroom and hand washing signs were posted. Hot water was tested and measured between 104.5 degrees F and 105.3 degrees F, which is within the required range.

GARAGE: The facility’s garage entrance is near the entryway. The garage contained emergency food and water, general storage, cleaning supplies, a staff refrigerator, and laundry machines. The laundry machines were operational and in good condition.

OUTDOOR AREA: The rear yard had two (2) shaded patios equipped with outdoor furniture in good condition for residents’ use. The facility had various options for outdoor activities in addition to a grill. There were two (2) emergency side exits with a self-latching mechanism and passageways remained clear.

RECORDS: Record review began at 11:01AM. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, LPA reviewed the facility’s infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually. Emergency disaster drills are conducted monthly, with the last drill documented on 08/14/2025. Two (2) fire extinguishers were fully charged and last serviced on 05/23/2025. Smoke and carbon monoxide detectors were tested at 12:48PM and were operational.

Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GONZALES FAMILY HOME	FACILITY NUMBER: 565801393
	VISIT DATE: 09/11/2025

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MEDICATIONS: Medication review began at 12:50PM. Medications were centrally stored and kept inaccessible in the office/activity area. Two (2) resident medications were reviewed and were properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025

LIC809 (FAS) - (06/04)

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