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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200243
Report Date: 10/13/2021
Date Signed: 10/13/2021 10:45:15 AM

Document Has Been Signed on 10/13/2021 10:45 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:VENTURA HILLS MANORFACILITY NUMBER:
079200243
ADMINISTRATOR:JES CARL BATACANFACILITY TYPE:
735
ADDRESS:1520 VENTURA AVENUETELEPHONE:
(510) 236-1001
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 14CENSUS: 12DATE:
10/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Jes C Batcan, AdministratorTIME COMPLETED:
10:50 AM
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On 10/13/2021 at 9:25am Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to conduct infection control inspection LPA's met with administrator, Jes Carl Batacan and explained the purpose of the visit

During the Infection Control Inspection, LPAs toured facility including but not limited to common areas, kitchen, bedroom, and shared bathrooms. to front entrance, screening station, hand washing stations, common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Hand washing posters, soap, and paper towel were observed at hand washing stations. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Visitors policy is posted on the front door. Facility staff were observed wearing masks. Facility has a 30-day supply of PPE maintained at a central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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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