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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850412
Report Date: 12/04/2025
Date Signed: 12/04/2025 02:37:18 PM

Document Has Been Signed on 12/04/2025 02:37 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:
12/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:31 PM
MET WITH:Jovilito GugarinTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 12:31 PM. LPA met with facility staff who contacted the facility Co-Administrator Jovilito Gagarin. The Co-Administrator arrived to the facility at approximately 12:45 PM. Entrance interview was conducted and the reason for the visit was explained.

Beginning at approximately 12:45 PM the LPA, along with the Co-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:

OUTDOOR SPACE/GARAGE: The facility has one (1) emergency exit gate located on the side of the home; LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. LPA observed the garage to contain extra oxygen supplies, care supplies, emergency water supplies, and an extra fridge/freezer. LPA observed the garage’s entrance to the interior of the facility to be locked and inaccessible to clients in care.

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured under-sink cabinet to contain cleaning chemicals and a secured drawer to contain knives and other sharp objects.

Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2025
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: 12/04/2025
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COMMON AREAS: This included the living room, hallway, office, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained an appropriately screened fireplace and activities for resident use. LPA observed a camera located in the living room LPA confirmed with the Co-Administrator that audio is not recorded. The hallway was observed to be clean and free from any obstructions. The hallway included a closet which contained the facility’s washer and dryer and a locked storage cabinet which contained laundry and cleaning chemicals. Additionally, the hallway contained storage cabinets which contained extra linens for resident use. The office was observed to be locked and inaccessible to clients in care and contained resident/facility files. The dining area was observed to be equipped with adequate seating for resident use. The dining area/living room contained all required postings. LPA observed the dining area to contain a wall mounted fire extinguisher that was fully charged and serviced on 11/05/2025. The facility’s combination fire and carbon monoxide alarms were tested at 01:40 PM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms.

BEDROOMS: There are four (4) bedrooms in the facility; two (2) are dual occupancy and two (2) are single occupancy resident rooms. LPA and the facility Co-Administrator toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a shared/common resident bathroom and one (1) is a private resident bathroom. Both resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured to be between 113.5 and 117.3 degrees Fahrenheit, which is in compliance with regulation.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 10/02/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Co-Administrator. Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
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: FELIZ HOME LLC
FACILITY NUMBER: 565850412
VISIT DATE: 12/04/2025
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INTERVIEWS: LPA interviewed one (1) resident. The resident interviewed stated that the staff treat them well and are attentive to their needs. The resident interviewed had no concerns with the facility. LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse

Due to time constraints LPA will return at a later date to conduct file review, medication review, and to collect copies of pertinent documentation. No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC809 (FAS) - (06/04)
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