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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609849
Report Date: 09/14/2021
Date Signed: 09/14/2021 05:25:25 PM

Document Has Been Signed on 09/14/2021 05:25 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:PCS - FERNWOODFACILITY NUMBER:
567609849
ADMINISTRATOR:DANIEL, DADESIIFACILITY TYPE:
735
ADDRESS:515 FERNWOOD DRTELEPHONE:
(805) 307-1810
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 4CENSUS: 4DATE:
09/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Dadesii Daniel - AdministratorTIME COMPLETED:
05:24 PM
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Licensing Program Analyst (LPA) JoAnn Rosales and Tri-Counties Regional Center Quality Assurance Specialist (QAS) Freddie Garcia conducted a joint Case Management visit at the above facility to investigate alleged incidents potentially occurring from August 23, 2021 to August 25, 2021 where staff pushed client #1 (C1) to the ground 7 days in a row and while in the shower C1 fell and staff would not assist C1 in getting up. C1 sustained a gnash to the knee in two places due to the fall.

During today's visit LPA and QAS toured the facility with staff Damiana Alaniz, interviewed clients and random staff, reviewed staff and client records and requested copies of pertinent client documents. At this time further investigation is required.

Exit interview was conducted, today's report was reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
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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