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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801861
Report Date: 03/16/2023
Date Signed: 03/16/2023 04:12:27 PM


Document Has Been Signed on 03/16/2023 04:12 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:ESTRELL HOME CARE LLCFACILITY NUMBER:
425801861
ADMINISTRATOR:RUBY Q. MARTINEZFACILITY TYPE:
740
ADDRESS:804 LAVONNE DRIVETELEPHONE:
(805) 354-0670
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:3CENSUS: 2DATE:
03/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Ester Martinez, StaffTIME COMPLETED:
04:45 PM
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Licensing Program Analysts (LPA's) Olson and Jeffries conducted an unannounced Annual visit to the facility above. LPA's met with Ester Martinez, Live In Caretaker at 9:20 AM, and explained the purpose of the visit. Staff stated there are 2 residents currently living in the facility.

The facility has 2 floors with 7 bedroom's, Downstairs has 1 staff room and 3 resident bedrooms, 2 resident bedrooms are occupied by single residents, and one resident bedroom is being used as a resident hobby office. There are 3 staff rooms and a staff living room upstairs. There is a sturdy fence at the base of the stairs separating the staff liven quarters from the resident liven quarters. LPA's observed all necessary postings in an office to the left of the entrance.

LPAs and staff toured the entire inside and outside of the facility. There is ample room outside for residents to be outdoors with a table, chairs and umbrella for shade. LPA's observed the refrigerator cabinets, microwave, and oven to be clean with enough food for residents. Medications were observed locked and secured in a cabinet located to the upper right of the kitchen sink. LPA's observed knives and sharps locked in a drawer. LPA's observed chemicals to be locked in the garage. LPA's tested the water temperature and observed it was at 119.2 degrees F. LPA's tested the fire/carbon monoxide detector and observed them to be working and operational. LPA's didn't observe any violations and observed the facility to be clean and in good repair with all passageways and exits to be free and clear of debris and obstacles.

LPA's conducted a cursory medication audit and reviewed MARs and medications paperwork. LPA's reviewed facility staff files for completeness. LPA's reviewed facility resident records for completeness. LPA's observed a fire extinguisher charged and recently purchased. LPA's and Staff conducted a full CARE Tool Facility Inspection. LPA's discussed with staff the new Infection Control Policies, Emergency Disaster Plan, and staff training's. LPA's Interviewed 2 staff and 2 residents who were present.
Exit Interview conducted, a copy for the report was issued to facility.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023
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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