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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801544
Report Date: 12/15/2023
Date Signed: 12/15/2023 04:48:19 PM

Document Has Been Signed on 12/15/2023 04:48 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:ARC OF VENTURA COUNTY - OXNARD, THEFACILITY NUMBER:
565801544
ADMINISTRATOR:JUAN GARCIAFACILITY TYPE:
775
ADDRESS:416 NORTH "A" STTELEPHONE:
(805) 240-1620
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 90CENSUS: 56DATE:
12/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Bonnie LermaTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management visit regarding a self-reported incident that occurred on 11/29/2023. LPA was joined by Tri-Counties Regional Center (TCRC) BCBA Quality Assurance Specialist (QAS) Stephanie Cole and TCRC QAS Katy Robison.

On 11/29/2023, Client 1 (C1) eloped from the facility. LPA and QAS interviewed clients at 9:30 a.m., 9:35 a.m., 9:40 a.m. and 9:49 a.m. Staff were interviewed at 9:08 a.m. and 10:05 a.m. LPA observed an exit which has a chime alarm to alert staff of anyone exiting the facility, however the chime alarm did not work.

It was witnessed that C1 exited the facility through the gate door that had the inoperable chime alarm. C1 left without staff supervision. A client witnessed C1 leave and alerted staff.

Staff 1 (S1) was assigned to C1 that day and had left for their group outing without C1. S1 was counseled by management and all of the staff received missing person training. This week, 12/13/2023, S1 had another incident of leaving C1 behind and S1's employment was terminated.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2023
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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Document Has Been Signed on 12/15/2023 04:48 PM - It Cannot Be Edited


Created By: Teresa Camara On 12/15/2023 at 10:28 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: ARC OF VENTURA COUNTY - OXNARD, THE
FACILITY NUMBER: 565801544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/18/2023
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds. (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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The senior supervisor will ensure that the chime alarms are all checked and operable by 12/18/2023.
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Based on observation, the licensee failed to ensure the chime alarm on the exit gate door was in working order which allowed a client to exit without staff noticing, which poses a potential health risk to clients in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023


LIC809 (FAS) - (06/04)
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