565800274-10-4-2023-29-AS-TCAA-CWAQW5-20231004123123

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800274
Report Date: 10/04/2023
Date Signed: 10/04/2023 12:31:37 PM

Document Has Been Signed on 10/04/2023 12:31 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	IRIS HOUSE		FACILITY NUMBER:	565800274
ADMINISTRATOR:	BARON GRAHAM		FACILITY TYPE:	735
ADDRESS:	1311 W. IRIS STREET		TELEPHONE:	(805) 486-9288
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 5		CENSUS: 4	DATE:	10/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Baron Graham		TIME COMPLETED:	12:40 PM

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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with caregiver Keith Smith and informed him of the reason for today's visit. When the LPA arrived there was one caregiver and three clients present. Administrator Baron Graham was contacted and informed of the inspection. LPA met with the administrator and assistant Administrator Brigitte Campbell. Graham had to leave at 12:10 p.m. so Campbell signed the report.

The facility is vendored by Tri-Counties Regional Center as a level 4-I home. The LPA and caregiver toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food and emergency water in the garage.

COMMON SPACES: All indoor and outdoor passages were free of obstruction. At the time of the visit, living room and dining room furniture was observed to be in good condition. The fire extinguisher is fully charged and last serviced on 02/13/2023. The carbon monoxide detector and smoke detectors in the home and bedrooms were tested and were operational. Medications are locked and centrally stored in a locked closet in the staff room/office. There is outdoor seating for client use. Cleaning supplies are stored in the locked garage.

(continued on 809-C)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: IRIS HOUSE	FACILITY NUMBER: 565800274
	VISIT DATE: 10/04/2023

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(continued from 809)

BEDROOMS: There are three client bedrooms downstairs and a staff bedroom upstairs. The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: The facility has one common hallway restroom and one private restroom. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. The hot water temperature in the hallway common restroom measured at 117.8*F.

INFECTION CONTROL: LPA spoke with the Assistant Administrator regarding the facility’s infection control practices. LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility can obtain more as needed. The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview and report reviewed with the Assistant Administrator. A copy of the report was emailed to the licensee.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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