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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850073
Report Date: 09/03/2025
Date Signed: 09/04/2025 07:31:00 AM

Document Has Been Signed on 09/04/2025 07:31 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:OCEAN BREEZE AT BLUE OAKFACILITY NUMBER:
565850073
ADMINISTRATOR/
DIRECTOR:		RAYAS, EVELYNFACILITY TYPE:
740
ADDRESS:1132 BLUE OAK STTELEPHONE:
(805) 482-7082
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 6DATE:
09/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Evelyn RayasTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. LPA initially met with facility staff, Cecilia Manuel. Administrator Evelyn Rayas was contacted and arrived shortly after the visit began. Entrance interview conducted.

The LPA, along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguishers are fully charged and last serviced on 04/07/2025. Hardwired combination smoke detectors and fire doors were tested at 12:06 P.M., separate carbon monoxide detector was tested at 12:09 P.M. and all were functional at the time of the visit. No fire clearance concerns were observed.

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food as well as emergency food. Cleaning supplies are located in a locked cabinet under the kitchen sink. Knives and sharps are locked and properly stored in a separate kitchen drawer next to the dishwasher.

COMMON AREAS: In the common areas, including the dining room and living room, walls and flooring were checked for cleanliness and good condition. At the time of the visit, the furniture was observed to be in good condition. The LPA observed the required postings in the common area. LPA observed the fireplace in the living room, which was adequately screened. Auditorial signals were observed in each door around the facility. The facility maintained a comfortable temperature of 71 degrees.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2025
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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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: OCEAN BREEZE AT BLUE OAK
FACILITY NUMBER: 565850073
VISIT DATE: 09/03/2025
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Continued from LIC 809

BATHROOMS: There are three (3) bathrooms for resident use. One (1) shared half bathroom was observed in the hallway, two (2) full bathrooms with walk-in showers are designated for resident use. Restrooms were observed to be equipped with slip-resistant surfaces and mats. Grab bars were observed in the bathrooms. The water temperature was measured in all three (3) bathrooms and initially measured between 100.8-103.5 degrees Fahrenheit; water heater temperature was adjusted during the visit. LPA observed a loose sink knob and a unsteady grab bar next to the toilet in the bathroom located between bedroom#1 and #2. Additionally, the bathroom between the kitchen and the family room has a broken towel holder.

BEDROOMS: There are six (6) total bedrooms in the facility; five (5) bedrooms are designated for resident use. Four (4) are for single occupancy and one (1) is a shared room. LPA observed one (1) staff room which was locked at the time of the visit. All residents’ rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

GARAGE: Garage was observed locked and contained laundry area, extra food, PPE and incontinence supplies, and emergency food and water. Cleaning compounds were stored in cabinets surrounding the washer and dryer and separately from food supplies.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. LPA observed two (2) side gates. During today’s visit, the self-latching mechanism on both side gates were inoperable. The administrator stated that the property owner was present on 09/02/2025 to assess these concerns and agreed to replace the larches on both gates. All passageways were observed to be clear. There were no bodies of water on the premises.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC809 (FAS) - (06/04)
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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: OCEAN BREEZE AT BLUE OAK
FACILITY NUMBER: 565850073
VISIT DATE: 09/03/2025
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Continued on LIC 809-C

RECORD REVIEW: Began at 12:28 P.M. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. LPA observed that two (2) out of six (6) resident files reviewed indicated that resident has no capability for self-care, and they are not on hospice, and there were no records indicating that an exception request was submitted to the department. All other required forms were complete. All five (5) staff files including the Administrator were observed to be in compliance with regulation. All training was observed to be complete.

MEDICATION REVIEW: Medications are kept in a locked kitchen cabinet. Additionally, inside the locked cabinet facility has resident’s records and a complete First Aid kit with a manual. Began at 2:20 P.M. Medications for six (6) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

LPA obtained Client Roster, Staff Roster, and Liability insurance. Last emergency drill was conducted on 07/17/2025.

LPA reviewed the facility’s Emergency Disaster Plan and the infection control plan. The plans were in compliance with regulations at the time of the visit.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/04/2025 07:31 AM - It Cannot Be Edited


Created By: Valeria Conway On 09/03/2025 at 04:03 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OCEAN BREEZE AT BLUE OAK
FACILITY NUMBER: 565850073

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having to fix a few issues around the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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The administrator agreed to fix or replace the broken towel holder, the loose knob, the unsteady grab and the self-latching mechanism on the side gates. Provide proof of repairs to LPA before due date.
Type B
Section Cited
CCR
87615(a)(5)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by having two residents in care that are not capable to self care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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Administrator agreed to communicate with resident's responsible person and physician to see if hospice is an option and if not they will have the residents reappraised by their physician to accurately reflect their capabilities. Licensee may submit appropriate documentation to CCL to obtain a exception to retain a total care resident.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2025


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