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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802000
Report Date: 02/10/2025
Date Signed: 02/10/2025 03:16:55 PM

Document Has Been Signed on 02/10/2025 03:16 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:DREAM HAVEN OF SANTA PAULAFACILITY NUMBER:
565802000
ADMINISTRATOR/
DIRECTOR:		GRACE CATABAYFACILITY TYPE:
740
ADDRESS:404 E. MAIN STREETTELEPHONE:
(805) 420-9605
CITY:SANTA PAULASTATE: CAZIP CODE:
93060
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
02/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Abygail Go Viera TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required 1-Year annual inspection. LPA initially met with staff and later met with Designee Abygail Go Viera. LPA explained the reason for the visit. Administrator Grace Catabay could not be present during the visit.

The LPA, along with staff, 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. Smoke alarms and the carbon monoxide detector were tested and functioned properly. The fire extinguisher appeared full and was purchased on 08/29/2024.

KITCHEN/FOOD SERVICE AREA: The facility had a sufficient supply of perishable food and non-perishable food. Knives and cleaning supplies were locked in drawers and cabinets. .

COMMON AREAS: The living and dining areas are furnished appropriately. The backyard area is enclosed and outdoor activity space. Medications were locked and centrally stored in the hall closet. Cleaning supplies are stored in the locked laundry room.

BATHROOMS: There are three full bathrooms and one half bathroom. One bathroom is used by staff, the main resident bathroom is in the hallway near the staff room, and one bathroom is in a resident's room and the half bathroom is in the office. The hot water temperature was measured at 108.3*F at 10:56 a.m. in the resident's main bathroom. The bathrooms were observed to be safe and sanitary with grab bars and non-skid mats and a supply of toilet paper, soap and paper towels.

BEDROOMS: There are six private resident bedrooms that were observed to be properly furnished, well lit and clean at the time of the visit.
Report will continue on LIC809-C, 2nd page.
Kasandra LopezTELEPHONE: (818) 596-4343
Esther CortezTELEPHONE: (747) 230-2225
DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: DREAM HAVEN OF SANTA PAULA
FACILITY NUMBER: 565802000
VISIT DATE: 02/10/2025
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INTERVIEWS: LPA interviewed two staff and two residents (other residents were not able to be interviewed). No immediate concerns were voiced at this time.

RECORDS REVIEW: At 11:21 a.m. a record review was initiated. The LPA obtained a resident roster and staff roster. The LPA reviewed Infection Control Plan, Emergency and Disaster Plan and last disaster drill (conducted on 01/28/2025 ). LPA reviewed records for five (5) residents and five (5) staff; Resident 1's (R1's) file did not contain proof of a negative TB test otherwise, all other were complete and current.

MEDICATION REVIEW: At 1:30 p.m. a medications review was initiated for two out of six residents and the following was observed: Medications are centrally stored in a locked closet; medications are labeled and checked for expiration dates. Medications were documented in the Centrally Stored Medication and Destruction Record (CSMDR).

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Abygail Go Viera.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/10/2025 03:16 PM - It Cannot Be Edited

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: DREAM HAVEN OF SANTA PAULA
FACILITY NUMBER: 565802000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of six residents file did not contain proof of a negative TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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Licensee will submit proof of a negative TB test for the identified resident to CCL no later than POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra LopezTELEPHONE: (818) 596-4343
Esther CortezTELEPHONE: (747) 230-2225

DATE: 02/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2025

LIC809 (FAS) - (06/04)
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