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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801556
Report Date: 06/20/2024
Date Signed: 06/20/2024 04:44:02 PM

Document Has Been Signed on 06/20/2024 04:44 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:DOLORES FAMILY HOMEFACILITY NUMBER:
565801556
ADMINISTRATOR/
DIRECTOR:		REBECCA G. HERNANDEZFACILITY TYPE:
735
ADDRESS:4540 FROST DRIVETELEPHONE:
(805) 488-3947
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 4CENSUS: 4DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Jeanette Graves-Co-administratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required - 1 Year inspection at the facility today. The LPA met with Co-administrator Jeanette Graves and explained the reason for the inspection. When the LPA arrived there were three (3) clients and two (2) staff present.

At 2:19 PM, the LPA, along with the co-administrator Jeanette 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. During the visit an additional staff and client arrived.

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. Knives and items that could pose a danger were secured in locked cabinets. Medications and facility records are stored in a locked cabinet in the dining area.
Common Areas: In the common areas, furniture, walls, and flooring were clean and in good condition at the time of the inspection. There is a fireplace in the living room that is properly screened. All indoor and outdoor passages were free of obstruction. The fire extinguisher was fully charged and last serviced on 06/12/2024. At 2:22 PM the carbon monoxide detector and smoke alarms in the common rooms and bedrooms were tested and operational. The facility has one common and one private restroom for client use. Restrooms were observed to be clean and sanitary with hand soap and paper towels. The hot water temperature in the common restroom measured at 117.0 degrees F. Cleaning supplies and disinfectants are stored in locked cabinets in the garage. The backyard has covered seating for client use. There are no bodies of water on the premises.
Bedrooms: The LPA observed the three client bedrooms. They were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

Report continued on LIC 809-C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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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: DOLORES FAMILY HOME
FACILITY NUMBER: 565801556
VISIT DATE: 06/20/2024
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RECORDS: At 2:40 PM a record review for four clients and five staff was conducted. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 05/18/2024). Client files reviewed were found to be complete. P&I money and records were reviewed. Cash resources were separate and intact, and not be commingled with facility funds or petty cash. The facility has a surety bond on file. Staff files reviewed were complete. The LPA obtained Client Roster, and Staff schedule.

MEDICATIONS: At 3:55 PM a medication audit was conducted. Medications are locked and centrally stored in the dining room. Medications for three clients were reviewed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record.

INTERVIEWS: The LPA conducted two (2) client and two (2) staff interviews. No immediate concerns voiced during today's visit.

Exit Interview conducted and a copy of this report has been issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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