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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801454
Report Date: 06/26/2024
Date Signed: 06/26/2024 12:26:29 PM

Document Has Been Signed on 06/26/2024 12:26 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:ARLENE'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
565801454
ADMINISTRATOR/
DIRECTOR:		CHARITO F RAMIREZFACILITY TYPE:
735
ADDRESS:4321 BROWNING DRIVETELEPHONE:
(805) 488-0322
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 5DATE:
06/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:42 AM
MET WITH:Charito RamirezTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez and Licensed Child Care Licensing Program Analyst Laura Villanueva conducted an unannounced Case Management Deficiency visit in conjunction with an initial 10-day complaint visit (CC #29-AS-20240618104544). At 09:42 a.m. when the LPAs arrived there were three (3) clients and no staff present. Administrator Charito Ramirez and Care staff Rolando Vitug were called and informed the LPAs were at the facility and arrived shortly thereafter. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint allegation.

When the LPAs arrived there were three (3) clients at the facility without any staff supervision. Administrator Charito Ramirez and Carestaff Rolando Vitug were called and informed the LPAs were at the facility. When carestaff Rolando Vitug arrived they stated they were driving to the park with their grandson.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D). A $500 immediate civil penalty is assessed today. Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2024
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 06/26/2024 12:26 PM - It Cannot Be Edited


Created By: Esther Cortez On 06/26/2024 at 11:59 AM
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: ARLENE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565801454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2024
Section Cited
CCR
80078(a)

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80078(a) Responsibility for providing care and supervision: The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by:
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Administrator agrees they will not leave clients unsupervised, submit LIC500 with specific days and hours shown for all staff. Administrator agrees to provide written statement acknowledging understanding of CCR 80078 in its entirety. Administrator agrees to conduct
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Based on observations and interviews conducted, the licensee did not comply with the section cited above as three clients were alone at the facility without any staff supevision at 9:42 a.m. on 06/26/24 which poses an immediate health and safety risk to clients in care.
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 a thorough training of 80078 in its entirety. Training to include Staff’s signature date of training.

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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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


LIC809 (FAS) - (06/04)
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