197609562-2-10-2023-29-AS-ECAS-CNWVNB-20230210153453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609562
Report Date: 02/10/2023
Date Signed: 02/10/2023 03:35:17 PM

Document Has Been Signed on 02/10/2023 03:35 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	APPLEGATE @ SIRIUS		FACILITY NUMBER:	197609562
ADMINISTRATOR:	CARMONA, IRMA		FACILITY TYPE:	740
ADDRESS:	2614 SIRIUS STREET		TELEPHONE:	(805) 380-9400
CITY:	THOUSANDS OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 6		CENSUS: 6	DATE:	02/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Irma Carmona		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Elsie Campos conducted an unannounced visit to Applegate @ Sirius to conduct a Required 1-Year Annual Inspection. This annual has a specific emphasis on infection control practices and procedures. The LPA was greeted and scanned at the door by staff, Ruby Bernardo. The Administrator, Irma Carmona arrived shortly after and was explained the reason for the visit. At 2:30 p.m., the LPA began the physical plant tour with the Administrator of the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Knives and chemicals are locked inaccessible. Appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The six single-occupancy resident rooms were furnished appropriately; beds had clean linens and rooms had sufficient lighting. All direct exits were clear and no obstructions were noted. RESTROOMS: Each resident room has an en suite restroom and there is one common restroom in the hallway. Restrooms were clean and sanitary with grab bars and non-skid surfaces. Between 2:45 p.m. and 2:50 p.m., water temperature measured between 116.2 and 128.3 F. Restrooms were fully stocked. Hand-washing signs were observed. COMMON SPACES: The LPA observed the living room area which is clean and properly furnished with seating, a table, and television for resident use. Smoke detectors and common monoxide detectors were operable at the time of the visit. Fire extinguishers were fully charged and serviced 3/16/2022. All exits have functioning auditory devices. The backyard had furniture and a covered patio set for resident use. The side gate door was self-latching. No bodies of water noted. GARAGE AND GROUNDS: The garage is locked and attached to the house. There is one (1) additional refrigerator and freezer in the garage with perishable items in good condition. Garage contains a laundry area, extra food supplies, personal protection equipment and incontinence supplies. ...Continued on LIC 809-C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: APPLEGATE @ SIRIUS	FACILITY NUMBER: 197609562
	VISIT DATE: 02/10/2023

NARRATIVE

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INFECTION CONTROL: There was a central entry point for screening and temperature checks. The LPA was appropriately screened upon entry into the facility. Staff were wearing appropriate face coverings. Infection Control signs were observed on the front door and throughout the facility. Facility has a sufficient supply of PPE. The facility’s cleaning protocol is sufficient. Staff continue to document temperatures of staff and residents on a daily basis. There was record of staff and resident vaccinations. All staff are fully vaccinated. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/10/2023 03:35 PM - It Cannot Be Edited

Created By: Elsie Campos On 02/10/2023 at 03:18 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: APPLEGATE @ SIRIUS	FACILITY NUMBER: 197609562
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as the water temperature measured above 120 degree F in 3 out of 6 bathrooms, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/14/2023
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Staff will adjust the water tank by the end of the day. Plan of correction met at the time of the visit. 2. Keep a water temperature for four (4) bathrooms (two (2) in each corridor) for three days. Submit the water temperature log no later than 2/14/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Elsie Campos

LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC809 (FAS) - (06/04)

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