565801418-9-23-2022-29-AS-MARO-CJJRAU-20220923125142

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801418
Report Date: 09/23/2022
Date Signed: 09/23/2022 12:52:33 PM

Document Has Been Signed on 09/23/2022 12:52 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:	GAINSBOROUGH OAKS		FACILITY NUMBER:	565801418
ADMINISTRATOR:	MARIA L. MACANDILI		FACILITY TYPE:	740
ADDRESS:	91 W. GAINSBOROUGH ROAD		TELEPHONE:	(805) 777-8802
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 3	DATE:	09/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Maria Macandili		TIME COMPLETED:	01:00 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), Martha Arroyo conducted an unannounced visit to the facility to conduct a Required 1-Year Annual Inspection with focus on Infection Control. The last annual conducted at this facility was on 7/24/2019. The LPA was greeted and screened at the door by caregiver, Wilfredo Macandili. The Administrator arrived shortly after and the reason for the visit was explained. Entrance interview.

At 10:30 a.m., the LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, staff room, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed one designated cabinet over the oven where knives and sharps are locked and inaccessible to residents. Medications are in a locked cabinet adjacent to the kitchen.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: Resident restroom is clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restroom is sufficiently stocked with hand liquid soap and paper towels. The appropriate hand-washing signs were observed throughout. Bathroom was measured for hot water and it measured at 119.5 degrees Fahrenheit.

…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: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

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 3

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: GAINSBOROUGH OAKS	FACILITY NUMBER: 565801418
	VISIT DATE: 09/23/2022

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

…Report Continued from LIC 809...

BACKYARD AND GROUNDS: The LPA observed the laundry room locked and inaccessible to residents in care. Cleaning supplies and chemicals are locked inside the laundry room. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. At 10:40 a.m., the LPA observed the pool gate unlocked accessible to residents in care. The Administrator stated there was someone that was coming to clean. LPA advised Administrator no bodies of water shall be accessible to residents. Administrator locked gate immediately.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. LPA observed temperature for the facility at 75 degrees Fahrenheit. Fire extinguisher was observed to be purchased on 9/15/2022.

During today’s visit, the 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. Staff were observed wearing face coverings. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. All staff and residents are fully vaccinated and boosted. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. Civil Penalties assessed today in the amount of $500. Appeal Rights Discussed. A copy of the report was provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/23/2022 12:52 PM - It Cannot Be Edited

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: GAINSBOROUGH OAKS	FACILITY NUMBER: 565801418
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(e)

87705(e) Care of Persons with Dementia. (e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as the gate leading to the swimming pool was not locked, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/23/2022
	Plan of Correction
1 2 3 4	Plan of Correction met. The Administrator ensured that the gate was locked. Zero Tolerance violation; a civil penalty was assessed during today's visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3