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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801423
Report Date: 01/03/2024
Date Signed: 01/03/2024 03:43:00 PM

Document Has Been Signed on 01/03/2024 03:43 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:HOUSE OF TRANSITIONFACILITY NUMBER:
565801423
ADMINISTRATOR:JESUS CARDENAS AMADORFACILITY TYPE:
772
ADDRESS:1750C SOUTH LEWIS ROADTELEPHONE:
(805) 437-2903
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY: 15CENSUS: 15DATE:
01/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Alesha Evans & Jordan Ward, Facility DesigneesTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a case management-deficiencies visit at the facility today. The LPA arrived at 09:55AM and met with Facility Designee Alesha Evans. Entrance interview conducted.

On 12/27/2023, the Woodland Hills Regional Office received 2 (two) incident reports via e-fax from this facility. One report was for an incident that occurred on 12/13/2023, involving Client #1 (C1), which resulted in C1 being hospitalized. The other incident report was for an incident that occurred on 11/11/2023 involving Client #2 (C2), which resulted in a call to 9-1-1 and C2 being transported to the hospital for further observation. Neither of these incidents were reported by telephone to the Regional Office and written reports were received well outside of the 7 (seven)-day time frame.

Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted with Facility Designee Jordan Ward. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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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Document Has Been Signed on 01/03/2024 03:43 PM - It Cannot Be Edited


Created By: Kelly Dulek On 01/03/2024 at 02:55 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: HOUSE OF TRANSITION
FACILITY NUMBER: 565801423

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2024
Section Cited
CCR
81061(b)(1)(E)

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81061 (b)Upon the occurrence...a written report…shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) (E) Any unusual incident...threatens the physical or emotional health or safety of any client.
This requirement is not met as evidenced by:
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Facility Designee agreed to send all written reports in timely. Designee will discuss with Program Director a training plan for all Management staff on reporting requirements and will submit proof of training to CCL by POC due date.
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Based on record review, incidents occurred on 11/11/2023 and 12/13/2023 and written reports were not received at the Regional Office until 12/27/2023, which poses a potential health and safety 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024


LIC809 (FAS) - (06/04)
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