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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850412
Report Date: 08/18/2025
Date Signed: 08/18/2025 04:27:41 PM

Document Has Been Signed on 08/18/2025 04:27 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: 6DATE:
08/18/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Jovilito GagarinTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Incident inspection at the facility today. The LPA met with Licensee representative Jovilito Gagarin and explained the reason for the inspection.

On 07/31/2025, Community Care Licensing (CCL) received an Unusual Incident/Injury Report (LIC 624) pertaining to Resident #1 (R1). The report stated that on 07/27/2025, about 4 pm, R1 while seated at the couch at the living room attempted to get up and fell on the floor on the right side of his body hitting the floor. A cut and bruise on the right elbow had resulted from that accident. Two staff (S1, S2) observed the incident. It was further reported that R1's responsible person was contacted the same day and notified of the incident. On, 07/29/25, R1's responsible party took R1 to the hospital and at the time of the report R1 was still at the hospital.

On 08/01/25, LPA Cortez conducted an interview with Licensee representative, Jovilito Gagarin telephonically , who stated they were informed from R1's responsible person that R1 had sustained a fracture. Additionally, Mr. Gagarin stated that R1 is a fall risk, and the week before R1 fell at the facility they had fallen at their responsible person home and believe the fracture was sustained from that fall.

During today's visit, the LPA conducted interviews with Licensee representative Jovilito Gagarin, two (2) staff, one (1) resident, and R1's responsible person (telephonically).

The 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: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2025
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: FELIZ HOME LLC
FACILITY NUMBER: 565850412
VISIT DATE: 08/18/2025
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Mr. Gagarin revealed that when they were informed of the incident, he had asked staff it it was serious because if it was they would have to call 911 and staff had informed them it was not so serious. Additionally, he revealed that after informing R1's responsible person (RP) about the incident, they asked the RP if they wanted them to call 911 and the RP asked them if it was serious and they replied no and the RP notified them they would visit R1 the following day. Lastly, Mr. Gagarin revealed that Staff accessed R1's body by pressing it and R1 did not screamed therefore they were not in excruciating pain.

S1 and S2 revealed that they did not witness R1's fall as one was in the kitchen and the other in the laundry room and R1 was sleeping in one of the recliners in the living room, they heard the fall and immediately went to the resident. After R1's fall, R1 complained about pain the same day and the following day and S1 applied warm water with a rag on his body. S1 revealed they notified their boss about the incident and it's up to the boss to determine if 911 is called or not. Both staff revealed that R1 had a prior fall just days before at R1's RP's home and believe R1 sustained a fracture then.

A telephonic interview with R1's RP revealed that they were notified of R1's fall and was told that everything was under control. However when they visited on 7/28, R1 was passed out and could not wake up, on 7/29 R1 had a scheduled doctor's appointment and the RP and staff could not get R1 up and were not able to get R1 to their doctor's appointment. RP notice something was wrong and R1 could not put weight on their leg, and was not able to walk. Prior to the fall R1 was able to walk short distances with their walker. Lastly, the RP revealed that they were never asked if staff needed to call 911, and that they were only told that an assessment had been done. They did not know the severity of the incident until Wednesday when they took R1 to the Emergency Room and was notified that R1 had a broken hip. RP also revealed that R1 had sustained two falls at their home a week prior to R1's fall at the facility and would fall once to twice a week at their home and believes the facility provides adequate care for R1.

The investigation revealed that on 7/27/25, R1 sustained a fall for which the facility staff did not obtain medical care, and on 07/29/2025, when R1's RP took R1 to the emergency room R1 was diagnosed with a broken hip. Based on the information obtained the Department found sufficient evidence to support that staff did not seek medical assistance for R1 in a timely manner.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/18/2025 04:27 PM - It Cannot Be Edited


Created By: Esther Cortez On 08/18/2025 at 03:33 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: FELIZ HOME LLC
FACILITY NUMBER: 565850412

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2025
Section Cited
CCR
87465(a)(1)

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(a) plan for incidental medical and dental care shall be developed by each facility. The...:(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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Licensee will submit a plan how you will ensure residents receive timely medical assistance. Submit to CCL by 08/19/2025.
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Based on staff interviews and records review the Licensee did not comply with the regulation above, staff did not seek medical assistance for R1 on 7/27/25, after a fall despite complaints of pain which posed an immediate health, safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2025


LIC809 (FAS) - (06/04)
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