565801423-8-28-2023-29-AS-KDUK-CV65HA-20230828195802

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801423
Report Date: 08/28/2023
Date Signed: 08/28/2023 07:58:08 PM

Document Has Been Signed on 08/28/2023 07:58 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: 15	DATE:	08/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Ayana Churn		TIME COMPLETED:	08:00 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) Kelly Dulek conducted a required annual visit and inspection. LPA met with Program Director Ayana Churn. Entrance interview conducted. Beginning at 11:23AM, the LPA, along with Administrator Jesus Cardenas 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. The following was observed: Fire extinguisher was observed to be fully charged and last serviced 11/16/2022. Carbon Monoxide detector was tested at 12:31PM and was functional at the time of the visit. 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. Knives and sharps are stored in a locked cabinet. There was an adequate supply of perishable and nonperishable food to accommodate 15 clients for one week. BEDROOMS: There were 15 bedrooms designated for client use. Ten (10) client bedrooms were observed during today's visit. All bedrooms observed were furnished for single occupancy and were properly furnished, including adequate supplies of bedding and linen. No visible hazards were observed. BATHROOMS: Each of the bedrooms observed included an individual half bathroom equipped with a sink and commode. All bathrooms observed were properly supplied with paper products and personal hygiene items and fixtures were observed to be functional at the time of the visit. There were four shower rooms, two at each end of the facility designated for client use. Water temperature was measured in various bathrooms throughout the facility and measured at 103.4 degrees Fahrenheit at 11:56AM in room 10's restroom, 102.6 Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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 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: HOUSE OF TRANSITION	FACILITY NUMBER: 565801423
	VISIT DATE: 08/28/2023

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

degrees Fahrenheit in room 9's bathroom, and measured at 102.2 degrees Fahrenheit in room 8's bathroom. Clients interviewed also indicated the water in the shower room is frequently lukewarm.

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 areas were adequately furnished to accommodate a maximum capacity of 15 clients. There is also a laundry room, which clients utilize. All hazardous cleaning chemicals were observed to be stored in a locked staff restroom.

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.

MEDICATIONS: Medications for five (5) clients were observed beginning at 12:05PM. All medications reviewed were stored and documented per regulation.

RECORD REVIEW: Beginning at 12:14PM, LPA reviewed staff and client files for but not limited to: client Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All five (5) client files reviewed contained all required documents. LPA reviewed five (5) staff files. Staff files reviewed were observed to contain the appropriate documents. LPA obtained documents to update the facility Administrator.

INTERVIEWS: During today's visit, LPA interviewed three (3) clients.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Disaster drills are conducted monthly, with the most recent drill documented on 08/10/2023.

Pursuant to Title 22 Division 6 Chapter 2 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted with Program Director Ayana Churn. Today’s reports and appeal rights were reviewed and provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/28/2023 07:58 PM - It Cannot Be Edited

Created By: Kelly Dulek On 08/28/2023 at 05:49 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOUSE OF TRANSITION	FACILITY NUMBER: 565801423
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

81088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). 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 in three (3) client restrooms the water temperature measured below the required temperature at 103.4 degrees F in room 10, 102.6 degrees F in room 9, and 102.2 degrees F in room 8, which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/15/2023
	Plan of Correction
1 2 3 4	Program Director agreed to submit a work order to adjust the water temperature and provide proof of work order and scheduled date of initial visit. Then take water temperatures in various client rooms at varying times of the day for a consecutive 5-day period, record the temperatures on a log, then submit the water temperature log to CCL by POC due date.

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:

Kristin Heffernan

LICENSING EVALUATOR NAME:

Kelly Dulek

LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3