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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607438
Report Date: 04/19/2022
Date Signed: 04/20/2022 09:26:29 AM

Document Has Been Signed on 04/20/2022 09:26 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BOROL PLACEFACILITY NUMBER:
197607438
ADMINISTRATOR:KATHY SHADEKO-ADEDIGBAFACILITY TYPE:
735
ADDRESS:2616 DAUNET AVENUETELEPHONE:
(805) 584-2995
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 4CENSUS: 3DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Isaac AdelekeTIME COMPLETED:
12:09 PM
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 10:34 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with back-up Administrator Isaac Adeleke and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and all functioned properly.

KITCHEN: Knives and cleaning supplies are stored in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: The LPA observed four single-occupancy client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: There were two restrooms which were clean and sanitary and in operating condition.

COMMON SPACES: At the time of the visit, living room and dining room furniture were observed to be in good condition. The LPA observed the required postings in the facility. The backyard patio is equipped with furniture for resident use. There was one self-latching gate on the side of the house.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. Staff needed to be reminded to wear masks while in common areas. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID.

No deficiencies were observed. Exit interview conducted and a copy of the report emailed to Administrator.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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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