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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801912
Report Date: 05/18/2023
Date Signed: 05/18/2023 10:10:39 AM


Document Has Been Signed on 05/18/2023 10:10 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:MCFADDEN ASSISTED LIVINGFACILITY NUMBER:
565801912
ADMINISTRATOR:OPHELIA MCFADDENFACILITY TYPE:
740
ADDRESS:1531 DWIGHT AVENUETELEPHONE:
(805) 419-6617
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 6DATE:
05/18/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Ophelia McFaddenTIME COMPLETED:
10:17 AM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a continuation of the required annual visit at 08:45 AM. LPA initially met with facility staff. Licensee was contacted via telephone and arrived at the facility at 08:55AM. Entrance interview conducted.

During today's visit, LPA reviewed and observed the following:

INTERVIEWS: Beginning at 08:53AM, LPA interviewed 2 (two) staff and 2 (two) residents.

MEDICATION REVIEW: Began at 09:20AM. Medications for 5 (five) residents were observed. All 5 (five) of 5 (five) residents' prescription medications were observed to be maintained and administered in compliance with regulation.


No citations issued. Exit interview conducted. A copy of today's report was provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
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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