565850412-12-1-2023-29-AS-TCAA-CY4W2R-20231201155447

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850412
Report Date: 12/01/2023
Date Signed: 12/01/2023 03:56:25 PM

Document Has Been Signed on 12/01/2023 03:56 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:	FELIZ HOME LLC		FACILITY NUMBER:	565850412
ADMINISTRATOR:	CARBAJAL, JESUSA		FACILITY TYPE:	740
ADDRESS:	709 OLIVIA DRIVE		TELEPHONE:	(805) 612-4198
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY: 6		CENSUS: 0	DATE:	12/01/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Amelita Gagarin		TIME COMPLETED:	02:15 PM

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Licensing Program Analyst (LPA) Teresa Camara conducted a pre-licensing visit to this property at 12:30 p.m. LPA met with applicant representatives Jesusa Carbajal, Amelita Gagarin, and Jovilito Gargarin. The applicant has obtained fire clearance for 6 (six) non-ambulatory residents with a facility capacity of 6 (six). The proposed facility has a pending Dementia care plan and a pending hospice care waiver for 3 (three) residents. Applicant completed component II interview on 11/17/2023 and component III was completed on 11/29/2023.

LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired combination smoke alarm and carbon monoxide detectors were tested at 1:05 p.m. and function properly. Fire extinguisher was observed to be fully charged and serviced 10/24/2023.

Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The common living and dining areas are clean and properly furnished. The fireplace is double sided and has screens on both sides. The office is located in the family room; records will remain in a locked cabinet. A working telephone is present. All required postings were observed in the common area. All chemicals and cleaning supplies were observed in the laundry room locked cabinets, the locked cabinet under the kitchen sink and a locked cabinet in the garage. A locked medication closet is in the hall adjacent to the dining room; it contained a first aid kit. The garage was observed to be locked and inaccessible to future residents and contained emergency water and supplies.

The proposed facility has 4 (four) bedrooms total, of which 2 (two) are private rooms and 2 (two) are shared rooms. All bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have appropriate linens. There is also an ample supply of linens, towels and paper products. The proposed facility has 2 (two) bathrooms, 1 (one) is designated for shared resident use and 1 (one) for private resident use. LPA observed night-lights were present in the hallways. Hot water measured at 116.1*F.

(continued on 809-C)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

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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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: FELIZ HOME LLC	FACILITY NUMBER: 565850412
	VISIT DATE: 12/01/2023

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(continued from 809)

The kitchen contained a sufficient supply of dishes, glasses and utensils. There is a sufficient supply of non-perishable food and water. The refrigerator temperature was 39*F and freezer was 0*F. Knives were stored in a locked cabinet under the stove top.

Building and grounds were observed. There is a covered patio area for residents' use. Outdoor exit gate was observed to be self-closing and self-latching. All passageways were observed to be clear of any hazards.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted and a copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

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