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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801728
Report Date: 02/02/2024
Date Signed: 02/05/2024 08:47:07 AM


Document Has Been Signed on 02/05/2024 08:47 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:SEA BREEZE MANORFACILITY NUMBER:
565801728
ADMINISTRATOR:ROSE MARIE LOPEZFACILITY TYPE:
740
ADDRESS:1511 OFFSHORE STREETTELEPHONE:
(805) 985-5995
CITY:OXNARDSTATE: CAZIP CODE:
93035
CAPACITY:6CENSUS: 5DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Divina BigayTIME COMPLETED:
03:45 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 back-up administrator Divina Bigay and explained the reason for the inspection. The 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.

KITCHEN: LPA inspected the kitchen. Knives are locked in a drawer and cleaning supplies are stored inaccessible in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. COMMON AREAS: The living room, family room and dining room areas were furnished appropriately and furnishings were in good condition. The facility maintained a comfortable temperature. Smoke detectors and carbon monoxide detector were tested and functioned properly. The fire extinguisher was fully charged and last serviced 1/30/2024. LPA observed required postings in the hallway. The backyard has a covered outdoor area equipped with furniture for client use. There is a latched self-closing side gate. No bodies of water noted. The garage has an alarm on the door. The washer, dryer, detergents, other supplies as well as additional non-perishable food items are located in the garage. BATHROOMS: The facility has four and one half bathrooms. There is a staff bathroom upstairs, two full bathrooms downstairs, one half bathroom downstairs and one private bathroom in a resident's room. Bathrooms were observed to be clean and sanitary with hand soap and paper towels. The hot water temperature measured at 116.7*F. BEDROOMS: There are four single-occupancy bedrooms for residents and one double-occupancy room. All rooms were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There is one bedroom for staff located upstairs along with an office.

RECORDS: LPA reviewed records for the three regularly scheduled staff; all were complete.

No deficiencies were observed during the inspection. LPA will return at a later date to finish the annual inspection. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
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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