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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850540
Report Date: 07/07/2025
Date Signed: 07/07/2025 01:43:46 PM

Document Has Been Signed on 07/07/2025 01:43 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: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: 30DATE:
07/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Samantha GonzalesTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Esther Cortez arrived at the Adult Day Program (ADP) unannounced to conduct a required annual visit at 9:20 a.m. The LPA met with Administrator Samantha Gonzales and explained the reason for the visit. The program currently operates from 8:30 a.m. to 2:30 p.m. The day program was staffed with 1:3 staff to consumer ratios.

At 9:35 a.m., the LPA and the Administrator toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility has hard wired and battery operated smoke alarms and carbon monoxide detectors. All battery operated smoke and carbon monoxide detectors were tested throughout the tour and were operational. The LPA observed fire extinguisher which was fully charged and last serviced 06/17/2025.

Common Activity Space: The facility consists of 2 (two) open activity areas, a kitchen, 2 (two) conference rooms, a staff area, various locked storage closets, locked office spaces, and 3 (three) individual restrooms, one of which is designated for staff use. The facility does not contain an outdoor activity space. All areas observed appeared to be clean, safe, sanitary, and in good repair at this time. Cleaning supplies are stored in a locked area. PPE supplies are stored in a locked office.
Activities: Activities are both designed for individual and as a group. Activity supplies were observed in the large activity room.
Food Service: The kitchen areas were clean and in good condition. Consumers bring their lunch and snacks. The facility has emergency food supplies and snacks available for consumers.

Report will continue on LIC809-C, 2nd page.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: SKILL DEVELOPMENT CENTER
FACILITY NUMBER: 565850540
VISIT DATE: 07/07/2025
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Restrooms: The bathrooms are safe and sanitary and in operating condition with toilet paper, soap, and paper towels. Hot water was measured in both designated client restrooms and measured within 106-112 F degrees.

Record Review: At 10:45 a.m. a review of facility files was initiated. The LPA obtained Client Roster, Staff Roster, and Staff schedule. The LPA reviewed five (5) of thirty (30) Client Files. All client files were complete and current. Starting at 11:57 a.m. the LPA reviewed the Guardian website, the Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined that one staff (S1) who is currently working in the facility has not been associated to the facility prior to their employment. Upon observation, the Administrator stated that they had received a background check clearance from the Department of Social Services (DSS) Care Provider Management Bureau (CPMB), however was not able to provide a copy to the LPA.

Medication Audit: Currently there are no clients that take medications at Day Program.



Interviews: The LPA conducted four (4) client and four (4) staff interviews. No immediate concerns were voiced during the visit.

Due to time constraints the LPA will return at a later time to complete the annual.

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 Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2025 01:43 PM - It Cannot Be Edited


Created By: Esther Cortez On 07/07/2025 at 01:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SKILL DEVELOPMENT CENTER
FACILITY NUMBER: 565850540

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019(e)(3)
Criminal Record Clearance
(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following: (3) Request the licensee or applicant for a license to request a transfer of a criminal record clearance as specified in Section 82019(f); or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in one staff (S1) who was not associated to the facility prior to working at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2025
Plan of Correction
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Administrator agreed to have S1 not work at the facility until associated and will submit a letter of understang of the regulation in its entirety and submit to LPA by 07/08/2025.
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 Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2025


LIC809 (FAS) - (06/04)
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