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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801728
Report Date: 02/23/2024
Date Signed: 02/23/2024 04:02:34 PM

Document Has Been Signed on 02/23/2024 04:02 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:SEA BREEZE MANORFACILITY NUMBER:
565801728
ADMINISTRATOR:ROSE MARIE LOPEZFACILITY TYPE:
740
ADDRESS:1511 OFFSHORE STREETTELEPHONE:
(805) 985-5995
CITY:OXNARDSTATE: CAZIP CODE:
93035
CAPACITY: 6CENSUS: 5DATE:
02/23/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Divina BigayTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a continuation of the required annual visit. LPA met with administrator Rose Marie Lopez and explained the reason for the visit.

During LPA's prior visit on 2/2/2024, LPA conducted a physical plant tour, health and safety check, and reviewed staff records. During today's visit LPA conducted interviews, reviewed records and medications.

RESIDENT INTERVIEWS AND RECORDS: LPA interviewed two residents; there were no concerns stated. LPA reviewed five residents' records. All records were complete with pre-admission appraisals, needs and services plans, physician reports, admission agreements, and emergency contact information. LPA reviewed medications which appeared to be given as prescribed.

STAFF INTERVIEWS AND RECORDS: LPA interviewed two staff who were all able to answer the questions appropriately; no concerns noted. During LPA's previous visit records were reviewed and all staff scheduled at the facility were fingerprint cleared and associated to the facility.

DISASTER PLAN: LPA reviewed the facility's disaster plan which appeared to be complete. The facility conducts quarterly evacuation drills with all staff.

No deficiencies were observed. Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2024
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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