565801357-3-3-2022-29-AS-KLOZ-CC6UTC-20220303145142

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801357
Report Date: 03/03/2022
Date Signed: 03/03/2022 02:52:18 PM

Document Has Been Signed on 03/03/2022 02:52 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:	EJ-3 FAMILY HOME		FACILITY NUMBER:	565801357
ADMINISTRATOR:	WILHELMINA ONG		FACILITY TYPE:	735
ADDRESS:	721 YALE PLACE		TELEPHONE:	(805) 986-5429
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 4		CENSUS: 4	DATE:	03/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:38 PM
MET WITH:	Jomar Ong and Maria Miranda		TIME COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required - 1 Year inspection. The LPA met with Co-Administrator Jomar Ong and explained the reason for the inspection. Co-Administrator Maria Miranda also arrived at the facility at 1:00 PM.

The facility is vendored by Tri-Counties Regional Center as a level 4-I home. This annual had a specific emphasis on infection control practices and procedures. The LPA 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.

KITCHEN: Beginning at 12:49 PM, the kitchen and food storage areas in the garage were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen and garage. Cleaning supplies and items that could pose a danger were secured and locked in the garage or locked storage.

COMMON SPACES: The common areas, including walls, furnishings, and flooring were checked for cleanliness and good condition. All indoor and outdoor passages were free of obstruction. The second story of the home is for staff use only and is secured by a locked door. The fire extinguisher was fully charged and last serviced on 02/08/2022. Beginning at 1:00 PM, the carbon monoxide detector and smoke detectors in the common areas and the two resident bedrooms were tested and were operational. Medications are centrally stored in a locked cabinet in the hallway. Linens were stored in a closet. Cleaning supplies were observed to be locked in the garage and inaccessible to residents in care. The backyard has covered seating for resident use.

BEDROOMS: There are two resident bedrooms on the first floor for resident use. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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: EJ-3 FAMILY HOME	FACILITY NUMBER: 565801357
	VISIT DATE: 03/03/2022

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RESTROOMS: The facility has one common restroom on the first floor for resident use. At 1:05 PM, the hot water temperature measured at 116.6 degrees F. The restroom was observed to be clean and sanitary with hand soap, toilet paper, paper towels, and a sign regarding proper hand washing techniques.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee Representative regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE). The facility’s cleaning protocol is sufficient. Infection control signs were posted at the entry, throughout the facility, and in the restrooms. 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’s policies and procedures as it pertains to infection control are adequate.

Co-Administrator Maria Miranda stated they will be submitted documentation to update with the current administrator of the home.

No deficiencies cited. Exit interview and reported reviewed with the Licensee Representative. A copy of the report was emailed.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

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