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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801393
Report Date: 10/06/2021
Date Signed: 10/06/2021 04:16:10 PM

Document Has Been Signed on 10/06/2021 04:16 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:VENIE G. GONZALESFACILITY TYPE:
735
ADDRESS:4450 BROWNING DRIVETELEPHONE:
(805) 488-2315
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 5DATE:
10/06/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Venie GonzalesTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Deficiencies inspection due to a deficiency observed during the investigation of 29-AS-20210803150520.

Interviews during the investigation revealed Staff #2 (S2) was left alone with Resident #1 (R1) and Resident #2 (R2) for approximately 25 minutes while Staff #1 (S1) was eating their lunch in another room. Both residents required 1:1 support.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted and report reviewed with Venie Gonzales. A copy of the report and appeals rights will be emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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 10/06/2021 04:16 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 10/06/2021 at 02:20 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: GONZALES FAMILY HOME
FACILITY NUMBER: 565801393

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2021
Section Cited
CCR
80065(a)

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80065 Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement is not met as evidenced by:
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The administrator shall ensure staffing ratios are followed per the residents IPP's and provide proof of staff training regarding the role and expectation of staff providing 1:1 support. Proof of training shall be submitted to the LPA by 10/14/21.
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Based on interviews, the licensee did not comply with the section above as interviews revealed one staff was providing care for two residents who need 1:1 support which poses an immediate health and safety risk to residents 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:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021


LIC809 (FAS) - (06/04)
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