565801182-12-7-2023-29-AS-ECOZ-CYAVK7-20231207152953

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801182
Report Date: 12/07/2023
Date Signed: 12/07/2023 03:30:36 PM

Document Has Been Signed on 12/07/2023 03:30 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:	ROSE GARDEN MANOR III		FACILITY NUMBER:	565801182
ADMINISTRATOR:	EMMANUEL SORATORIO		FACILITY TYPE:	740
ADDRESS:	831 YALE PLACE		TELEPHONE:	(805) 986-6097
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 5	DATE:	12/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Amalia Soratorio		TIME COMPLETED:	03:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required - 1 Year Inspection. The facility is vendored by Tri-Counties Regional Center as a level 4-E home. When the LPA arrived there was nobody at the home, the LPA contacted Licensee Amalia Soratorio who arrived at 10:11 a.m. and explained to them the reason for the visit. The residents were at day program during todays visit and all arrived at 1:23 p.m. At 10:34 a.m. the LPA conducted a tour of the physical plant with the Licensee to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of two (2) living rooms, five (5) resident bedrooms, one (1) staff room, and two (2) restrooms. The LPA observed two (2) fire extinguishers which were fully charged and last serviced 10/05/2023. At 10:41 a.m. all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings through out the home. Kitchen: During the facility tour at 10:34 a.m. the kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are always available for the residents. Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Restrooms: The client restrooms were observed to be clean, sanitary and fixtures were in operating condition. At 10:44 a.m., the hot water in the common hallway bathroom measured at 112.6 degrees Fahrenheit. Report will continue on LIC809-C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: ROSE GARDEN MANOR III	FACILITY NUMBER: 565801182
	VISIT DATE: 12/07/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Common areas: These included the living rooms and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. There is a fireplace in the second living room, which is covered with a screen. The facility maintained a comfortable temperature of 67 degrees. There were no obstructions and/or tripping hazards throughout the facility.

Garage: The LPA observed the garage, where the washer and dryer are held, and the emergency water is stored. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. The garage is not locked.

Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises.
Infection Control: The home has an adequate supply of Personal Protection Equipment (PPE) and can obtain additional supplies. The home’s policies and procedures pertaining to infection control were adequate.

Record Review: The LPA reviewed resident and staff records at 11:24 a.m. The LPA reviewed all five resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, consent forms, and current needs and services plan. All files were complete. Five (5) out of ten (10) staff files were reviewed. The LPA reviewed five staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid/CPR cards. All files were complete. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 11/30/2023). The LPA obtained a Client Roster, Staff Roster, and copy of Insurance liability.

Medications: At 02:11 p.m. a medication review was initiated. Medications are centrally stored and locked in a hallway closet; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. The LPA inspected the first aid kit, which was complete with a first aid manual.
Interviews: At 02:42 p.m. the LPA conducted two (2) staff and two(2) resident Interviews. No immediate concerns were voiced.
Exit interview conducted and copy of the report provided to Licensee Amalia.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2