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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850412
Report Date: 12/12/2024
Date Signed: 12/12/2024 01:26:49 PM

Document Has Been Signed on 12/12/2024 01:26 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:FELIZ HOME LLCFACILITY NUMBER:
565850412
ADMINISTRATOR/
DIRECTOR:		CARBAJAL, JESUSAFACILITY TYPE:
740
ADDRESS:709 OLIVIA DRIVETELEPHONE:
(805) 351-9099
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 4DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:32 AM
MET WITH:Jovilito GagarinTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Rankin arrived at 8:32 am to conduct a 1-year annual visit to the facility above. LPA met with Administrator Jovilito Gagarin and explained the purpose of the visit.

Upon arrival 2 staff were noted as being present as well as two nurses conducting visits. Residents were eating or being assisted in the living room area. Around 9:12 am a tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Physical Plant & Environment Safety: The facility has 4 resident bedrooms, 2 bathrooms and currently occupies 4 residents with 2 live in staff. The facility has smoke and carbon monoxide detectors that were tested and working properly during the visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked under sink and in the laundry room. The facility has a fenced backyard for client use with plenty of shade. The fire extinguishers were charged and last inspected in November of 2024.

Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance which expires on 1/17/2025. The facility is approved for a capacity of 6. The fire clearance is granted for 6 Non-Ambulatory. Recent hospice increase is approved for 5.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
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: FELIZ HOME LLC
FACILITY NUMBER: 565850412
VISIT DATE: 12/12/2024
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Personnel Records & Training: Staff files had current 1st Aid/CPR, file reviewed for required documentation, files were found complete. Administrator certificates expires 08/08/2025. Current staff have only worked for the facility for the past month, medication and dementia training are complete, additional training is scheduled to be completed in the next 2 weeks.

Resident Records & Incident Reports: Facility does submit incident reports to the department when required. LPA reviewed 4 resident files, ensured updated Appraisals Needs and Services Plan were documented, and all other required documents were available.

Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables, to meet the food service requirement. All food is covered, stored, and marked. Food, snacks, and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies.

Incidental Medical Services: Facility provides assistance in arranging transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed and discussed residents’ medications, medication practices and documentation, all are in compliance.

Disaster Preparedness: The current emergency disaster form was reviewed and discussed with administrator. The facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. Additional review of this document is being done to ensure staff assignments are clear and resources for outages are available.

Residents with Special Health Needs: The facility does accept dementia residents in care. The facility has 1 gate, it was self-closing and self-latching. Facility currently has one residents on oxygen. The facility currently has 3 hospice resident in care. The facility does not have any residents receiving Home Health services at this time. The facility does not have delayed egress.

Exit interview conducted and copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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