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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609849
Report Date: 04/03/2024
Date Signed: 04/03/2024 02:56:51 PM

Document Has Been Signed on 04/03/2024 02:56 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:
ADMINISTRATOR/
DIRECTOR:		DANIEL, DADESIIFACILITY TYPE:
735
ADDRESS:515 FERNWOOD DRTELEPHONE:
(805) 307-1810
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 4CENSUS: 4DATE:
04/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Dadesii "Didi" DanielTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management - incident visit regarding a self-reported incident which took place on 3/25/2024 involving client 1 (C1). LPA was accompanied by Tri-Counties Regional Center Quality Assurance Specialists (QAS) Liz Aced-Arnett and Patrick Brown. LPA met with administrator Didi Daniel and explained the reason for the visit.

At 11:15 a.m. LPA and QASs interviewed Lead Staff (S1) and the administrator together. LPA reviewed and obtained documents starting at 12:45 p.m.

Further investigation is needed. LPA will return at a later date to finalize the investigation.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
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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