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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801393
Report Date: 03/08/2022
Date Signed: 03/08/2022 04:57:03 PM

Document Has Been Signed on 03/08/2022 04:57 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:
03/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Venie GonzalesTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Incident inspection at the facility. Tri-Counties Regional Center Quality Assurance Specialist (QAS) Liz Aced-Arnett was also present. Entrance interview conducted. Administrator Venie Gonzales arrived at the facility at approximately 10:20 AM.

The reason for today's inspection was to follow up on a self reported incident which occurred on 02/20/2022 pertaining to Client #1 (C1). On 02/20/2022, C1 informed staff in the morning that their shoulder hurt and staff observed C1's arm to be swollen. C1 was taken to the urgent care and was diagnosed with a dislocated shoulder. Staff reported no witnessed falls or incidents. C1 has a private bedroom. C1 was also unable to state how the injury occurred.

During today's inspection, the LPA and QAS conducted interviews with the Administrator, Staff #1 (S1), and C1 between 10:20 AM and 11:30 AM. Interviews revealed it was unclear how C1's injury occurred. The LPA and QAS discussed night time supervision with the Administrator. The facility has 24 hour awake staff. The Administrator stated staff check the clients at night frequently but there is no set policy on a specific number of times the client are checked at night. It was discussed with the Administrator quantifying how often staff are checking clients at night and documenting the staff checks.

No deficiencies were cited during today's inspection. The Administrator was unable stay for the entire inspection but was advised of the report findings. Exit interview and report reviewed with staff Rustum Placio. Report will be emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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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