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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610023
Report Date: 12/10/2024
Date Signed: 12/10/2024 01:30:05 PM

Document Has Been Signed on 12/10/2024 01:30 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:A TIMIA OASISFACILITY NUMBER:
197610023
ADMINISTRATOR/
DIRECTOR:		JHA, AKHILESH KUMARFACILITY TYPE:
740
ADDRESS:15116 ROXFORD STREETTELEPHONE:
(310) 995-4859
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 6CENSUS: 5DATE:
12/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Flordeliz Chico - StaffTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced case management visit at this facility in conjunction with a complaint investigation control no.: 31-AS-20241127155153. LPA met with staff Flordeliz Chico who called the Designee Patria Dufrenne and the reason for the visit was explained. Ms. Dufrenne designated Ms. Chico to sign the report.

On 12/05/24 at around 9:30 AM. LPA & Licensing Program Manager (LPM) Troy Agard conducted a physical plant tour of the four (4) facilities on the property from 9:30 AM to 10:15 AM. The following health and safety violations were observed at this facility:

1) The door leading to the common area was propped open by the sofa at the living area.

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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Document Has Been Signed on 12/10/2024 01:30 PM - It Cannot Be Edited


Created By: Jose Gary Tan On 12/10/2024 at 12:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A TIMIA OASIS
FACILITY NUMBER: 197610023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/10/2024
Section Cited
CCR
87307(d)(6)

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Personal Accommodations and Services: The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction.
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The staff freed the door from the furniture and during this visit, the door has no obstruction. Cleared during visit.
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This requirement is not met as evidenced by:

Based on LPA and LPM's observation, the licensee did not ensure that the door leading to common area is free of obstruction. This poses a potential health and safety risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
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