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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610549
Report Date: 12/10/2024
Date Signed: 12/10/2024 03:04:07 PM

Document Has Been Signed on 12/10/2024 03:04 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:AN UBARI OASISFACILITY NUMBER:
197610549
ADMINISTRATOR/
DIRECTOR:		SZALONEK, FEFACILITY TYPE:
740
ADDRESS:15116 1/2 ROXFORD STREETTELEPHONE:
(747) 246-3242
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 6CENSUS: 3DATE:
12/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Flordeliz Chico - StaffTIME VISIT/
INSPECTION COMPLETED:
03:00 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-20241127152622. 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) Trash, recycling and other waste materials were obstructing the gate

2) No certified administrator for this facility.

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 03:04 PM - It Cannot Be Edited


Created By: Jose Gary Tan On 12/10/2024 at 12:32 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: AN UBARI OASIS
FACILITY NUMBER: 197610549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2024
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.

This requirement is not met as evidenced by:
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The designee agreed to clean up the trash and submit a photo of completion on or before the POC date.
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Based on LPM and LPA obsevation, Licensee did not ensure that the gate is free of obstruction which poses a potential health and safety and personal rights risk to the residents in care.
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Type B
12/17/2024
Section Cited
CCR87405(a)

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Administrator - Qualifications and Duties: All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person…

This requirement is not met as evidenced by:
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The designee agreed to appoint an administrator for this facility and submit the change of administrator request to CCL on or before the POC date.
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Based on record review, the licesee did not ensure that the facility has an Administrator as the Administrator on record is no longer working at this facility. 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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