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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850412
Report Date: 11/17/2023
Date Signed: 11/17/2023 09:35:07 AM

Document Has Been Signed on 11/17/2023 09:35 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:FELIZ HOME LLCFACILITY NUMBER:
565850412
ADMINISTRATOR:GAGARIN, AMELITA BFACILITY TYPE:
740
ADDRESS:709 OLIVIA DRIVETELEPHONE:
(805) 612-4198
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: DATE:
11/17/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Amelita Gagarin, Jesusa CarbajalTIME COMPLETED:
09:28 AM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): 0
COMP II Participants: Amelita Gagarin, Jesusa Carbajal
Interview Method: Telephone interview
On November 17, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restricted/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Jude De La Concepcion
LICENSING EVALUATOR NAME: Bethany Hunter
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
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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