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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801768
Report Date: 03/08/2022
Date Signed: 03/08/2022 09:07:56 AM

Document Has Been Signed on 03/08/2022 09:07 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:OUR HOME THOUSAND OAKS 3FACILITY NUMBER:
565801768
ADMINISTRATOR:STEVE MATEFACILITY TYPE:
740
ADDRESS:334 BURTON COURTTELEPHONE:
(805) 418-7803
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 0DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Steve MateTIME COMPLETED:
09:00 AM
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On 03/04/2022, Licensing Program Analyst Ashley Smith arrived at this location unannounced at 8:45 a.m. to conduct a required one year annual, with an emphasis on infection control practices. No one was available at the time of the visit. The LPA called Licensee Erika Vasko-Mate, whom informed the LPA that the location was closed.

Today, the LPA conducted a visit today at 8:45 a.m. with Administrator Steve Mate. The purpose of this visit is to document the closure of this facility and ensure all residents have been relocated. The LPA conducted a physical plant tour at 8:50 a.m. and observed no residents at this location.

Closure of this facility has been confirmed. Exit interview conducted and a copy of the report was issued. Licensee will send license to the office.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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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