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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801457
Report Date: 10/15/2021
Date Signed: 10/15/2021 04:06:43 PM

Document Has Been Signed on 10/15/2021 04:06 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: 4DATE:
10/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Leo LubidTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent Case Management - Incident inspection at the facility today. The LPA initially met with caregiver Leo Lubid at 11:57 AM. At 12:00 PM the LPA spoke with Licensee Representative Venie Gonzales on the telephone and explained the reason for today's inspection. Ms. Gonzales gave permission for the caregiver to sign the report in her absence.

The reason for today's inspection is to issue a final report for the investigation that began on 08/04/2021 pertaining to a self reported incident. The self-reported incident report stated it was reported by an individual in the home on 07/27/2021, that Staff #1 (S1) allegedly tapped Resident #1 (R1) on the shoulder with an open hand. S1 was interviewed by Venie Gonzales but they reportedly had no recollection of the incident. S1 was then placed on administrative leave. On 08/04/2021 at 10:00 AM, LPA Lopez and Quality Assurance Specialist (QAS) Katy Robison conducted a Collateral inspection at the current residence of R1. Although, the LPA and QAS were unable to interview R1 though due to their disability. On 08/04/2021, the LPA and QAS also conducted an inspection at the facility and reviewed facility records. On 09/08/2021, the LPA and QAS conducted a Collateral inspection and interviewed Resident #2 (R2) at 2:28 PM. On 09/30/2021, the LPA and QAS conducted a subsequent inspection at the home and interviewed Venie Gonzales. On 10/07/2021 a telephone interview was conducted with S1 at 2:04 PM and on 10/08/2021, a telephone interview was conducted with Staff #2 (S2).

Interviews revealed S1 allegedly hit R1 with a kitchen towel after R1 had a behavior episode. During interviews with S1, they denied hitting R1 with their hand or a kitchen towel. S2 who was working the day of the alleged incident, denied observing any usual or inappropriate actions by S1 and R1 on this day or any other day. Based on the information obtained there is insufficient evidence to support the allegation occurred. No deficiencies are being cited at this time. Ms. Gonzales was informed of the findings during the telephone call. A copy of the report will be emailed to Ms. Gonzales.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2021
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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