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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801457
Report Date: 10/04/2023
Date Signed: 10/04/2023 04:02:53 PM

Document Has Been Signed on 10/04/2023 04:02 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:CARING HOMEFACILITY NUMBER:
565801457
ADMINISTRATOR:KARISMA G. ABRIGOFACILITY TYPE:
735
ADDRESS:655 BERKSHIRE PLACETELEPHONE:
(805) 271-9921
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 3DATE:
10/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Vanessa GarciaTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with staff 1 (S1) and explained the reason for the visit. No clients were present at the facility during LPA's visit. All clients were in day programs. Administrator, Vanessa Garcia, met with LPA at 1:50 p.m.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food and emergency water in the garage. The hot water temperature was 112.8*F.

COMMON SPACES: All indoor and outdoor passages were free of obstruction. Living room and dining room furniture was observed to be in good condition. The fire extinguisher is fully charged and last serviced on 07/26/2023. The carbon monoxide detector and smoke detectors in the home and bedrooms were tested and were operational. Medications are locked and centrally stored in a cabinet in the hallway. There is outdoor seating for client use. Cleaning supplies are stored in a locked cabinet in the garage.

BEDROOMS: There are four client bedrooms and no staff room. The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.





(Report continued on LIC 809-C)
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARING HOME
FACILITY NUMBER: 565801457
VISIT DATE: 10/04/2023
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(continued from 809)


RESTROOMS: The facility has one common restroom and one private restroom. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels.

INFECTION CONTROL: LPA observed an adequate supply of Personal Protective Equipment (PPE) and the licensee can obtain more if needed. The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview and report reviewed with the administrator. A copy of the report was emailed to the licensee.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC809 (FAS) - (06/04)
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