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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609722
Report Date: 09/05/2024
Date Signed: 09/05/2024 04:23:53 PM


Document Has Been Signed on 09/05/2024 04:23 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:GRANNYS HOMEFACILITY NUMBER:
567609722
ADMINISTRATOR:HERNANDEZ, VICTORFACILITY TYPE:
740
ADDRESS:1831 BERNADETTE STTELEPHONE:
(805) 278-2273
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:6CENSUS: 5DATE:
09/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Victor HernandezTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPA met with Administrator Victor Hernandez and assistant administrator Celesty Hernandez and explained the reason for the visit. Entrance interview conducted. Administrator Victor had to leave during the visit and designated assistant administrator Celesty to review and sign the report.

The reason for today's inspection is to follow up on a self-reported death report received on 08/30/2024. The report pertains to the death of Resident #1 (R1). Per the information received, the circumstances surrounding the death of Resident #1 on 08/30/2024 may be questionable and needs to be investigated. It was reported R1 was sent to the hospital on August 17th and passed away on August 30th due to UTI/Sepsis at the hospital.

During today's visit, the LPA conducted an interview with the Administrator and Assistant administrator, conducted a brief tour of the facility and obtained copies of pertinent documents.

This incident was referred to Community Care Licensing Investigations Branch (IB) and assigned to investigator Christine Ferris. Further investigation is required prior to issuing findings. An investigator or the LPA will return at a later date.

Exit interview conducted. A copy of the report was issued to the assistant Administrator.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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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