565801423-9-27-2021-29-AS-KDUK-C79VVD-20210927164611

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801423
Report Date: 09/27/2021
Date Signed: 09/27/2021 04:46:58 PM

Document Has Been Signed on 09/27/2021 04:46 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:	HOUSE OF TRANSITION		FACILITY NUMBER:	565801423
ADMINISTRATOR:	CHRISTOPHER BLUM		FACILITY TYPE:	772
ADDRESS:	1750C SOUTH LEWIS ROAD		TELEPHONE:	(805) 437-2903
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY: 15		CENSUS: 12	DATE:	09/27/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Jennifer Beltran and Denise Gonzalez		TIME COMPLETED:	03:38 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) Kelly Dulek conducted a required annual visit and inspection. LPA met with the Jennifer Beltran and Denise Gonzalez. Program Director/Administrator Christopher Blum was unavailable today. A tour of the physical plant was initiated at 11:30am. LPA was accompanied by the office staff. KITCHEN: The facility is equipped with two separate kitchens designated as Kitchen A and Kitchen B. Both kitchens were equipped with fixtures and appliances that appeared clean and functional. There was an adequate supply of perishable food to accommodate 15 clients for two days and nonperishable food to accommodate 15 clients for one week. BEDROOMS: There were 15 bedrooms designated for client use. All bedrooms were furnished for single occupancy and were properly furnished and had adequate supplies of bedding and linen. No visible hazards were observed. BATHROOMS: Each of the 15 bedrooms included an individual half bathroom equipped with a sink and commode. All bathrooms were properly supplied with paper products and personal hygiene items and fixtures were observed to be functional at the time of the visit. There was one bathroom located in the main entrance designated for staff use only. There were four shower rooms, two at each end of the facility designated for client use. COMMON AREAS: These included two dining areas, one adjacent to each Kitchen and designated as A and B. There were two Living Rooms, one adjacent to each dining area also designated as A and B. All common Report continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

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: HOUSE OF TRANSITION	FACILITY NUMBER: 565801423
	VISIT DATE: 09/27/2021

NARRATIVE

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areas were adequately furnished to accommodate a maximum capacity of 15 clients.

SURROUNDING GROUNDS: The surrounding grounds included Parking Lots, Walkways, and Lawns. There were various shady areas available for clients. There were no immediate or imminent hazards observed.

INFECTION CONTROL: During today’s visit, the LPA spoke with the office staff regarding the facility’s infection control practices at 1:20PM. There is 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. 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 and shower 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.

At the conclusion of the visit,office staff Jennifer Beltran and Denise Gonzalez met with LPA; exit interview conducted. No citations issued. A copy of report provided via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

LIC809 (FAS) - (06/04)

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