565801728-2-17-2026-29-AS-ECOZ-DR5VRN-20260209154012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801728
Report Date: 02/09/2026
Date Signed: 02/17/2026 09:02:23 AM

Document Has Been Signed on 02/17/2026 09:02 AM - 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 MANOR		FACILITY NUMBER:	565801728
ADMINISTRATOR/ DIRECTOR:	ROSE MARIE LOPEZ		FACILITY TYPE:	740
ADDRESS:	1511 OFFSHORE STREET		TELEPHONE:	(805) 985-5995
CITY:	OXNARD	STATE: CA	ZIP CODE:	93035
CAPACITY: 6		CENSUS: 6	DATE:	02/09/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Rose Marie Lopez		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with administrator Rose Lopez and explained the reason for the inspection. 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 02/01/26). The LPA advised the administrator that disaster drill needed to be conducted for all shifts. The LPA obtained Client Roster, Staff Roster and Insurance liability. The LPA reviewed five(5) out of six (6) 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. However one residents appraisal needs and services plan is one month overdue. Otherwise, all resident and staff records were complete and current. The LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Knives are locked in a drawer and cleaning supplies are stored inaccessible in a locked cabinet and in the locked garage. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The LPA observed the stove knobs without covers. COMMON AREAS: The living room, family room and dining room areas were furnished appropriately and furnishings were in good condition. The facility maintained a comfortable temperature. Smoke detectors and carbon monoxide detector were tested and functioned properly. The fire extinguisher was fully charged and last serviced 2/06/2026. Report will continue on LIC809-C, 2nd page.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 MANOR	FACILITY NUMBER: 565801728
	VISIT DATE: 02/09/2026

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The LPA observed required postings in the hallway. The backyard has a covered outdoor area equipped with furniture for resident use. There is a latched self-closing side gate. No bodies of water noted. The garage is locked and inaccessible to the clients. The washer, dryer, detergents, other supplies as well as additional non-perishable food items are located in the garage.

BATHROOMS: The facility has four and one half bathrooms. There is a staff bathroom upstairs, two full bathrooms downstairs, one half bathroom downstairs and one private bathroom in a resident's room. Bathrooms were observed to be clean and sanitary with hand soap and paper towels. The hot water temperature measured at 112.*F. in the resident communal restroom near the entrance.

BEDROOMS: There are four single-occupancy bedrooms for residents and one double-occupancy room. All rooms were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There is two bedroom for staff located upstairs.

MEDICATIONS: Medications review was conducted for three (3) residents; 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: The 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.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026

LIC809 (FAS) - (06/04)

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