565801321-10-24-2022-29-AS-AASO-CKHUNZ-20221024154448

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801321
Report Date: 10/24/2022
Date Signed: 10/24/2022 03:47:46 PM

Document Has Been Signed on 10/24/2022 03:47 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:	CORTES ADULT FAMILY HOME		FACILITY NUMBER:	565801321
ADMINISTRATOR:	CONSUELO CORTES		FACILITY TYPE:	735
ADDRESS:	316 WALNUT DRIVE		TELEPHONE:	(805) 485-3445
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY: 6		CENSUS: 4	DATE:	10/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Elvia Lemus		TIME COMPLETED:	02:30 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) Angel Ascencio conducted an unannounced required annual visit to the above facility. LPA Ascencio met with the staff Elvia Lemus and explained the reason for the visit. Licensee Floro Cortes was not able to join LPA but authorized staff Lemus to sign documents. This home is vendor through Tri-Counties Regional Center. This annual had a specific emphasis on infection control practices and procedures. At 1:15 p.m., the LPA, along with staff member toured the physical plant areas inside and outside to ensure there are no health and safety hazards. BEDROOMS: All client rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are four (4) total bedrooms – two (2) are shared client rooms , and 2 are staff rooms. RESTROOMS: There are 2 total bathrooms at the home for client use. The client bathrooms have a shower with non-skid materials. The toilet and showers have grab bars.Hot water temperature was tested throughout the home and was within normal ranges between 105.0 F and 120.0 F. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

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: CORTES ADULT FAMILY HOME	FACILITY NUMBER: 565801321
	VISIT DATE: 10/24/2022

NARRATIVE

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The LPA observed the required postings in the common hallway. Fire extinguishers
were observed to be serviced within the last year. The facility smoke alarm system and carbon monoxide detector was tested and operated normally at the time of visit. Medications were observed to be locked in a cabinet by the kitchen and contained at least 30 days of worth of medication. Locked cabinet in the hallways contained a locked storage area for laundry supplies. The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted.

KITCHEN: Kitchen knives are stored in a locked cabinet in the kitchen. The supply of dishes,
utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees
Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation
area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had
tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located
in the hallway. No flies or other vermin were observed

INFECTION CONTROL: During today’s visit, the LPA spoke with staff Lemus regarding the
facility’s infection control practices at 1:40 p.m. There is 1 entry into the facility. Upon entry, the
facility has a central entry point for symptom screening. The LPA noted that the facility is allowing
visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of Personal
Protective 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 facility does not have a confirmed case of COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate.

No citations were issued during today’s visit.

Exit interview conducted, and a copy of the report provided to Admin via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

LIC809 (FAS) - (06/04)

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