565800650-4-30-2024-29-AS-SURA-D4TKH5-20240430075432

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800650
Report Date: 04/29/2024
Date Signed: 04/30/2024 07:55:11 AM

Document Has Been Signed on 04/30/2024 07:55 AM - 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:	GLOUCESTER HOUSE		FACILITY NUMBER:	565800650
ADMINISTRATOR:	BARON GRAHAM		FACILITY TYPE:	735
ADDRESS:	771 JOYCE DRIVE		TELEPHONE:	(805) 271-5086
CITY:	PORT HUENEME	STATE: CA	ZIP CODE:	93041
CAPACITY:	4	CENSUS: 4	DATE:	04/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:04 AM
MET WITH:	Baron Graham		TIME COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with House Manager Angela Orozcoand explained the reason for the visit. Manager contacted the Administrator Baron Graham on the phone and the administrator arrived shortly thereafter. LPA informed the administrator the reason for the visit.

The LPA and the House Manager toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives are stored in the locked staff room/office and cleaning supplies are locked in the garage.

BEDROOMS: The LPA observed one shared client bedroom and two single-occupancy client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: Restroom was clean and sanitary and in operating condition. Soap and paper towels were available for client use.

COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings. The carbon monoxide and smoke alarms were tested and functioned properly. The fire extinguishers appeared fully charged and were last inspected on 2/20/2024.

Continues on LIC 809C ...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

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: GLOUCESTER HOUSE	FACILITY NUMBER: 565800650
	VISIT DATE: 04/29/2024

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OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client and emergency use. No bodies of water noted. The washer and dryer are in the garage area, including additional perishable food items. Cleaning supplies and disinfectants are kept locked in the garage area.

RECORDS: Records review began at 12:05 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 1:25 p.m.; medications are centrally stored and locked in the locked staff room/office. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA reviewed the following documents:

- LIC9020 Client Roster

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC809 (FAS) - (06/04)

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