565801451-5-11-2022-29-AS-AASO-CEBKUL-20220511081251

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801451
Report Date: 05/10/2022
Date Signed: 05/11/2022 08:13:44 AM

Document Has Been Signed on 05/11/2022 08:13 AM - 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:	LONG LIFE HOME CARE		FACILITY NUMBER:	565801451
ADMINISTRATOR:	DELIA D. CAFUIR		FACILITY TYPE:	735
ADDRESS:	1887 CESAR CHAVEZ DRIVE		TELEPHONE:	(805) 604-0321
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY: 5		CENSUS: 5	DATE:	05/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:52 AM
MET WITH:	Delia Cafuir		TIME COMPLETED:	11:25 AM

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 Analysts (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 9:52 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Delia Cafuir and discussed the reason for the visit. The LPA, along with Administrator, toured the physical plant areas inside and outside at 10:15 a.m. to ensure there are no health and safety hazards. Entrance interview conducted. BEDROOMS: The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are seven (7) total bedrooms – two (2) are shared rooms, one (1) is private and four (4) are for staff rooms. RESTROOMS: One (1) restroom for client use was observed to be clean and sanitary and in operating condition. The bathroom and shower was also observed to have grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products in the restroom, as well as hand washing posters. Water temperature was tested and was within normal ranges. 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. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. Smoke detectors and carbon monoxide was observed to be in operable condition at the time of visit. The backyard has a covered area equipped with furniture for client use. There are no bodies of water noted. Garage was observed to be locked and contained emergency food supply. Medication was observed to be locked and contained at least a 30-day supply. Continued on LIC 809-C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

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: LONG LIFE HOME CARE	FACILITY NUMBER: 565801451
	VISIT DATE: 05/10/2022

NARRATIVE

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KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable
and non-perishable food. Water temperature was observed to be within normal limits. All knives and cleaning
supplies were observed to be locked and properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s
infection control practices at 10:45 a.m. LPA received the newest, updated Infection Control Plan on 05/02/2022. There is one (1) entry into the facility. Upon entry, the facility has a central point for symptom screening. 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 is be able to obtain more through Department of Public Health or Tri-Counties Regional Center. 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’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:

- Post PINs and educate staff, residents, and families on changing policies and procedures from the
Department

No citations were issued today's visit. Exit interview conducted. Copy of the report provided to Admin via
email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

LIC809 (FAS) - (06/04)

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