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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850540
Report Date: 03/12/2025
Date Signed: 03/12/2025 11:28:26 AM

Document Has Been Signed on 03/12/2025 11:28 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SKILL DEVELOPMENT CENTERFACILITY NUMBER:
565850540
ADMINISTRATOR/
DIRECTOR:		GONZALES,SAMANTHAFACILITY TYPE:
775
ADDRESS:2100 OUTLET CENTER DR STE B310TELEPHONE:
(805) 505-1100
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: 70CENSUS: 24DATE:
03/12/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:32 AM
MET WITH:Samantha GonzalezTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Esther Cortez conducted a case management visit at the Day Program (DP) regarding a self-reported incident that occurred on 03/08/2025. The LPA met with Administrator Samantha Gonzales and explained the reason for the visit. Administrator had to leave the DP at 11:25 a.m. and assigned the Admin Assistant Christian Barnes to review and sign the report.

It was reported that on 03/10/2025, Client 1 (C1) spoke to their skills coach privately and showed them multiple linear cuts on their left arm, each cut was about 3-4 inches, and informed their skills coach that they had self- harmed at home on 03/08/2025.

During today's visit the LPA conducted an interview with the Administrator. Administrator revealed that they have removed any potential items that C1 could use to self-harm, have increased supervision for C1, and are providing support to C1 and their family. C1 was at an outing during today's visit.

Based on all of the information obtained, staff appeared to have acted appropriately, are providing support including contacting appropriate agencies and a family member as required. No deficiencies are cited at this time. Exit interview conducted. A copy of the report issued

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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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