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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801728
Report Date: 02/25/2025
Date Signed: 02/25/2025 04:22:11 PM

Document Has Been Signed on 02/25/2025 04:22 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/
DIRECTOR:
ROSE MARIE LOPEZFACILITY TYPE:
740
ADDRESS:1511 OFFSHORE STREETTELEPHONE:
(805) 985-5995
CITY:OXNARDSTATE: CAZIP CODE:
93035
CAPACITY: 6CENSUS: 5DATE:
02/25/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Rose Marie LopezTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a continuation of the required annual visit on 02/06/25. LPA met with staff and explained the reason for the visit. Administrator Rose Marie Lopez arrived at approximately at 2:30 PM.

During LPA's prior visit on 2/06/2025, LPA conducted a physical plant tour, health and safety check.. During today's visit LPA conducted interviews, reviewed records and medications.

RECORDS: A review of facility files was initiated. Facility records are stored in the locked office upstairs. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 02/03/2025). The LPA obtained Client Roster, Staff Roster and Insurance liability. The LPA reviewed five(5) out of five (5) resident files and four (4) out of four (4) staff files. All records were complete with pre-admission appraisals, needs and services plans, physician reports, admission agreements, and emergency contact information. All records were complete and current for both residents and staff.

MEDICATIONS: Medications review was initiated; medications are centrally stored and locked in a closet in a hallway; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.

INTERVIEWS: LPA interviewed two residents and two staff; no concerns were voiced

No deficiencies were observed. Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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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