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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801457
Report Date: 09/30/2021
Date Signed: 09/30/2021 06:42:26 PM

Document Has Been Signed on 09/30/2021 06:42 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:CARING HOMEFACILITY NUMBER:
565801457
ADMINISTRATOR:KARISMA G. ABRIGOFACILITY TYPE:
735
ADDRESS:655 BERKSHIRE PLACETELEPHONE:
(805) 271-9921
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
09/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Venie GonzalesTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Incident inspection at the facility today. Tri-Counties Quality Assurance Specialist (QAS) Katy Robison was also present. Administrator Venie Gonzales arrived at the facility at 1:01 PM.

Today's inspection is a subsequent visit for the self reported Incident Report received on 07/27/2021 pertaining to Resident #1 (R1) and Staff #1 (S1). During today's inspection an interview was conducted with Administrator Venie Gonzales.

The LPA has determined further investigation is needed. Exit interview and report reviewed with Venie Gonzales. A copy of the report will be emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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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