197610210-10-7-2021-31-AS-APAA-C7KTL2-20211007144850

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610210
Report Date: 10/07/2021
Date Signed: 10/07/2021 02:50:02 PM

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CASTLEMERE SENIOR HOME II		FACILITY NUMBER:	197610210
ADMINISTRATOR:	JOSEPH-NURSE, VERONICA		FACILITY TYPE:	740
ADDRESS:	23780 VIA IRANA		TELEPHONE:	(661) 888-0432
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91355
CAPACITY:	6	CENSUS: 0	DATE:	10/07/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Veronica Joseph-Nurse - Administrator		TIME COMPLETED:	03:00 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	At approximately, 1:25pm Licensing Program Analysts (LPAs) Angela Panushkina and Shira Stamps conducted an announced Pre Licensing visit to this facility and met with the Administrator Veronica Joseph-Nurse. The applicant is "Castlemere Senior Homes II". Fire Clearance dated 09/13/2021 was received for five (5) non-ambulatory residents and one (1) bedridden in Room #3. Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. The facility is a single storey building, Today's site visit consisted of LPAs touring the physical plant inside and outside and observed the following: The facility dual smoke/carbon monoxide alarm system is hard wired and interconnected. The fire extinguishers located in the kitchen and in a garage areas were observed to be fully charged and were serviced on 08/26/2021. Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested at 1:45pm and observed to be operational. Hot water was tested in the common bathroom and measured at 120.0°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall and in a kitchen area with other posting requirements. There are five (5) resident bedrooms, four (4) private and one (1) shared room. No room is designated for staff due to facility will hire only awake staff at this time. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records will be stored in a locked cabinet near the kitchen area. Medications will also be stored in the locked cabinet. The first aid kit is readily available. There are two (2) bathrooms in the facility and both bathroom has non-skid mat and appropriate grab bars installed.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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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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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASTLEMERE SENIOR HOME II	FACILITY NUMBER: 197610210
	VISIT DATE: 10/07/2021

NARRATIVE

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At approximately, 1:35pm LPAs toured the kitchen and observed the kitchen knives being locked and inaccessible to residents in care. Kitchen cleaning supplies are stored in a locked cabinet under the kitchen sink. Appliances in the kitchen appeared to be functional.
At 1:45pm, LPAs observed laundry detergents, cleaning supplies and other toxins are stored in the garage. The laundry area is located in the garage. The garage is attached and is currently being used for emergency, perishable foods and other supplies storage. The garage was observed to be locked. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair.
At approximately, 1:50pm LPAs toured the outside area and observed there is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. There is no body of water in the facility.

Component III was conducted with the Administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted with the Administrator Veronica Joseph-Nurse and a copy of this report was provided.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC809 (FAS) - (06/04)

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