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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561704034
Report Date: 11/06/2023
Date Signed: 11/06/2023 12:05:29 PM

Document Has Been Signed on 11/06/2023 12:05 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:CAMARILLO HEALTH CARE DISTRICTFACILITY NUMBER:
561704034
ADMINISTRATOR:MARY ANN RATTOFACILITY TYPE:
775
ADDRESS:3639 EAST LAS POSAS ROAD #117TELEPHONE:
(805) 388-1952
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 40CENSUS: 6DATE:
11/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:Mary Ann RattoTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Required Annual inspection at the day program today and met with Administrator Mary Ann Ratto. Entrance interview conducted.

When the LPA arrived there were six (6) participants and two (2) staff present. Beginning at 09:39AM, the LPA, along with Administrator, toured the physical plant areas to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

The fire safety inspection related to the facility's pull system was last conducted on 01/04/2023 and no violations were observed at that time. Carbon Monoxide Detector was tested at 11:38AM and functioned properly.

Kitchen/Food Service: The food service area was observed. The day program serves lunch and snacks to the participants. Menu is posted. Food was observed to be stored, prepared and served in a safe and healthful manner. Knives are stored in a locked drawer. Cleaning supplies are locked in a cabinet under the sink. The fire extinguisher in the kitchen was fully charged and last serviced on 09/04/2023.

Restrooms: There are three unisex restrooms for participant use. Restrooms were observed to be clean and sanitary and in operating condition with grab bars and hygiene supplies. LPA measured the hot water in participant restroom, which measured within the required range.

Common Areas: The facility contains a dining room/activity area, as well as an additional activity area, indoor gardening center and two (2) resting areas for participants if needed. The activity schedule was posted and supplies were observed. The required postings were observed.

Medications: Medication room was observed to contain a lockbox inside a locked cabinet. Medication records are also stored inside the cabinet. First aid kit was observed to be complete. At this time no participants

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2023
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: CAMARILLO HEALTH CARE DISTRICT
FACILITY NUMBER: 561704034
VISIT DATE: 11/06/2023
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require medications administered during program hours, so no medications were observed.

Record Review: Staff and participant records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, participant physician's report, needs and service appraisal, and personal rights. All five (5) staff files and five (5) participant files observed were in compliance with regulation.

Infection Control/Emergency Disaster Plan: During today’s visit, the LPA reviewed the facility's infection control plan. The facility's policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's Emergency Disaster Plan, which was observed to be complete and updated annually. Administrator indicated that all staff are oriented on the facility's emergency plan and the facility will conduct an emergency drill prior to the end of the calendar year.

Interviews: LPA interviewed two (2) participants and two (2) staff.



No deficiencies were observed during today's inspection. Exit interview conducted. A copy of today's report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC809 (FAS) - (06/04)
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