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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801451
Report Date: 05/05/2023
Date Signed: 06/02/2023 08:30:48 AM

Document Has Been Signed on 06/02/2023 08:30 AM - 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:LONG LIFE HOME CAREFACILITY NUMBER:
565801451
ADMINISTRATOR:DELIA D. CAFUIRFACILITY TYPE:
735
ADDRESS:1887 CESAR CHAVEZ DRIVETELEPHONE:
(805) 604-0321
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 5CENSUS: 5DATE:
05/05/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Melanie CafuirTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a continued required annual visit at 10:06 a.m. When LPA arrived, there was one staff and two clients getting in the facility van to leave. Staff called the administrator Delia Cafuir who arrived within five minutes. LPA spoke with one client while waiting. LPA explained the reason for the visit to administrator.

LPA continued the required annual visit. LPA interviewed one staff and one client. The rest of the clients were at day program or in the community.

LPA reviewed the P&I (personal & incidental) money for all five clients; all records were in order. LPA reviewed the facility's emergency evacuation records; drills with clients are held monthly.

No deficiencies observed. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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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