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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850274
Report Date: 07/12/2023
Date Signed: 07/12/2023 05:42:44 PM


Document Has Been Signed on 07/12/2023 05:42 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:PETIT OASISFACILITY NUMBER:
565850274
ADMINISTRATOR:VINCECRUZ, SUSANFACILITY TYPE:
740
ADDRESS:2802 PETIT STREETTELEPHONE:
(805) 383-8894
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:6CENSUS: 3DATE:
07/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:38 PM
MET WITH:Roberto RamirezTIME COMPLETED:
05:53 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek conducted a case management - deficiencies visit at the facility today. LPA met with Licensee Roberto Ramirez at 04:58PM and explained the reason for today's visit.

During today's visit, LPA observed that Staff #1 (S1) and Staff #2 (S2) both have fingerprint background clearances, but are not associated to this facility. Interview revealed that S1 has been employed since 07/11/2023 and S2 has been employed since 07/06/2023 at the facility.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty issued in the amount of $700. Failure to correct the deficiency may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
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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Document Has Been Signed on 07/12/2023 05:42 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: PETIT OASIS
FACILITY NUMBER: 565850274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2023
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
This requirement is not met as evidenced by:
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During today's visit, LPA verified staffs' identification and associated both S1 and S2 to the facility in Guardian. Licensee indicated Administrator will fax over the transfer forms for S1 and S2 to be associated to the licensee's other facilities on 07/13/2023.
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Based on observation and interview, the licensee did not comply with the above cited section, as S1 has been employed beginning last night and S2 has been employed since 07/06/2023 and neither S1 nor S2 were associated to the facility, which poses an immediate safety risk to persons in care.
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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.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
LIC809 (FAS) - (06/04)
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