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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610531
Report Date: 12/05/2024
Date Signed: 12/05/2024 02:31:15 PM

Document Has Been Signed on 12/05/2024 02:31 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 SIWA OASISFACILITY NUMBER:
197610531
ADMINISTRATOR/
DIRECTOR:		SZALONEK, FEFACILITY TYPE:
740
ADDRESS:15112 ROXFORD STREETTELEPHONE:
(747) 246-3242
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 6CENSUS: 5DATE:
12/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Patria Dufrenne - DesigneeTIME 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 to cite the deficiency discovered while investigating complaint control no.:31-AS-20241127154156. During LPA's record review, LPA discovered that Staff #1 (S1) is not associated at this facility during this visit.

Citation issued. Civil penalty assessed. 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: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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 12/05/2024 02:31 PM - It Cannot Be Edited


Created By: Jose Gary Tan On 12/05/2024 at 01:28 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 SIWA OASIS
FACILITY NUMBER: 197610531

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2024
Section Cited
CCR
87355(c)(1)

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A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: (1) A signed Criminal Background Clearance Transfer Request, LIC 9182
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Administrator will send proof of association or will send an association documents for S1 to CCL on or before the POC date, if unable to log in at Guardian.
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This requirement is not met as evidenced by:

Based on record review, licensee did not ensure that S1 is associated at this facility which poses an immediate health, safety and personal rights 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: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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