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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801727
Report Date: 10/03/2023
Date Signed: 10/03/2023 11:15:40 AM

Document Has Been Signed on 10/03/2023 11:15 AM - 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:SAINT ROQUE FAMILY HOME CAREFACILITY NUMBER:
565801727
ADMINISTRATOR:BARBARA BROWNINGFACILITY TYPE:
735
ADDRESS:1610 KIPLING COURTTELEPHONE:
(805) 874-1762
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 5DATE:
10/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Barbara Browning, AdministratorTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident inspection. At 9:40 a.m., the LPA met with staff and explained the reason for the visit. At 9:56 a.m., the Administrator arrived at the facility.

The reason for today's inspection is to follow up on a self-reported death report received on 09/28/2023. The report pertains to the death of Client #1 (C1). At 9:56 a.m., an interview was conducted with the Administrator and Staff #1 (S1). At 11:06 a.m., the LPA conducted a brief tour of the facility. During the time of the visit, the LPA obtained copies of pertinent documents.

A referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB). No immediate health and safety concerns were observed during today's inspection. Additional report may follow if warranted.

Exit interview conducted and report reviewed with the Administrator. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
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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