565801019-2-7-2023-29-AS-MARO-CNU2DA-20230207161801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801019
Report Date: 01/27/2023
Date Signed: 02/07/2023 04:18:51 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/07/2023 04:18 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:	MOUNTAIN VISTA OF OJAI		FACILITY NUMBER:	565801019
ADMINISTRATOR:	NICKIE PEREZ		FACILITY TYPE:	740
ADDRESS:	602 EAST OAK STREET		TELEPHONE:	(805) 646-6850
CITY:	OJAI	STATE: CA	ZIP CODE:	93023
CAPACITY:	38	CENSUS: 26	DATE:	01/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Nickie Perez		TIME COMPLETED:	01:40 PM

NARRATIVE

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Licensing Program Analyst (LPA), Martha Arroyo arrived unannounced to conduct a Required 1-Year Annual with focus on Infection Control. The last Annual visit conducted at this facility was on 02/25/2022. Upon arrival, LPA met with Administrator Nickie Perez and the reason for the visit was explained. Entrance Interview.

At 11:19 a.m., the LPA along with the Administrator began the physical plant tour of the common areas kitchen area, resident bedrooms, bathrooms, staff room, office, and outdoor area to ensure there are n􀀁 health and safety hazards and facility is in compliance with Title 22 Regulations.

LPA observed five resident bathrooms for hot water temperature; the first bathroom measured at 105.8 degrees Fahrenheit at 11 :22am: second bathroom measured 107 .6 degrees Fahrenheit at 11 :25am; third bathroom measured 114.8 degrees Fahrenheit at 11 :31am: fourth bathroom measured 114.8 degrees Fahrenheit at 11 :33am; and fifth bathroom measured 109.4 degrees Fahrenheit at 11 :37am. The garage is detached and locked at all times. LPA observed an adequate amount of perishable and non-perishable food. Cleaning supplies and toxins were observed locked and inaccessible. LPA observed the fire extinguishers fully charged from 3/01/2022. The smoke detectors and carbon monoxide detectors were tested and operable at the time of visit. LPA observed medications locked inside the medication room. Laundry room is kept locked at all times inaccessible to resident in care. The facility was maintained at 73 degrees Fahrenheit at the time of visit. LPA observed outdoor grounds with clear passageways free of obstruction. No bodies of water observed at the time of visit.

Report Continued on LIC 809C ...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

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: MOUNTAIN VISTA OF OJAI	FACILITY NUMBER: 565801019
	VISIT DATE: 01/27/2023

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Report Continued from LIC 809 ...

During today's visit, LPA spoke with the Administrator regarding the facility's infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing. and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVlD-19. All staff are fully vaccinated and boosted. No identified staffing concerns.

Exit interview conducted. No citations issued during today's visit. Report was reviewed and issued to Administrator.

This document was recreated due to a glitch in the system not saving after replicating. Original copy on file with signatures.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC809 (FAS) - (06/04)

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