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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609849
Report Date: 09/20/2023
Date Signed: 09/20/2023 03:06:43 PM

Document Has Been Signed on 09/20/2023 03:06 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:PCS - FERNWOODFACILITY NUMBER:
567609849
ADMINISTRATOR:DANIEL, DADESIIFACILITY TYPE:
735
ADDRESS:515 FERNWOOD DRTELEPHONE:
(805) 307-1810
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 4CENSUS: 4DATE:
09/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Dadesii DanielTIME COMPLETED:
02:29 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced required annual visit to the above facility. LPA met with administrator Dadesii Daniel and explained the reason for the visit.
LPA conducted a review of staff files, client files, medications, P&I money, emergency drills and evacuation plan starting at 9:58 a.m. LPA interviewed two staff and one client starting at 12:48 p.m. LPA toured the physical plant areas inside and out starting at 12:03 p.m. which included testing the smoke and carbon monoxide detectors which functioned properly. The fire extinguisher was last serviced on 2/15/2023.

BEDROOMS: All client rooms were appropriately furnished and clean. Lighting in the rooms appeared adequate. There are 4 (four) total bedrooms for client use – all of which are private rooms.

RESTROOMS: There are two (2) bathrooms for client use. There is an additional bathroom which is used as storage of hygiene items and remains locked. The client bathrooms have showers with non-skid mats. The hot water temperature was measured at 112.4*F.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. Common seating areas and dining room furniture was observed to be in good condition. Required postings were observed in the common hallway. The medication room was observed to be locked and contained 30 days of medication. Medications appear to be given as prescribed. P&I money is kept locked in the administrator's office located on the second floor. The garage was observed locked and contained the laundry area and emergency food and water supply. The backyard has a covered outdoor area equipped with furniture for resident use.
(Continued on LIC 809C)
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
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: PCS - FERNWOOD
FACILITY NUMBER: 567609849
VISIT DATE: 09/20/2023
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(continued from 809)

KITCHEN: Kitchen knives are stored in the locked medication room. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides/poisons/toxins stored in any food storage area or food preparation area. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Cleaning supplies are stored in a locked cabinet under the sink or locked in the garage. No flies or vermin were observed.

INFECTION CONTROL: LPA spoke with the administrator regarding the facility’s infection control practices. LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate.

No citations were issued during today’s visit. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC809 (FAS) - (06/04)
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