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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801456
Report Date: 03/25/2022
Date Signed: 03/25/2022 11:41:39 AM

Document Has Been Signed on 03/25/2022 11:41 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,
, CA
FACILITY NAME:CEDAR HOUSEFACILITY NUMBER:
565801456
ADMINISTRATOR:ROSALIE MACATIAGFACILITY TYPE:
735
ADDRESS:161 MARKER AVENUETELEPHONE:
(805) 484-0271
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 6DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Louisa Mae CervantesTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 9:48AM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with staff Glicera (Noemi) Esleta and discussed the reason for the visit. Licensee Julia Espena and Administrator Louisa Mae Cervantes arrived at the facility at 10:43AM.

The facility is vendorized by Tri-Counties Regional Center as a Level III home. The LPA, along with facility staff Noemi, 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:

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room, dining room, and den furniture was observed to be in good condition. A fireplace was observed and was adequately screened. The LPA observed the required postings in the common area.

The backyard has a covered outdoor area equipped with furniture for client use. Gates were observed to be closed and latched, not locked. Garage was observed unlocked, however, the garage contained separate locked cabinets for chemical storage and laundry supplies as well as emergency food/water supply and storage.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives were observed to be locked in a kitchen drawer.

Fire extinguisher is fully charged, but was purchased on 03/23/2019. Smoke detectors and carbon monoxide detectors were tested at 10:22AM and were operational at the time of the visit.

BEDROOMS: The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report Continued on LIC 809-C

SUPERVISORS NAME:
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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,
, CA
FACILITY NAME: CEDAR HOUSE
FACILITY NUMBER: 565801456
VISIT DATE: 03/25/2022
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There are 4 (four) total bedrooms; 3 (three) shared rooms are for client use and 1 (one) is designated as a staff room.

RESTROOMS: The LPA observed 3 restrooms in the facility; one is a common shared restroom and 2 (two) are private restrooms. All restrooms are clean and sanitary and in operating condition with non-skid surfaces.

INFECTION CONTROL: During today’s visit, the LPA spoke with care staff regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and hand sanitization. LPA observed all staff to be wearing masks, however clients are not consistently encouraged to wear face coverings in common areas. 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 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:
-N95 fit testing for all staff
- Post PINs and educate staff, residents, and families on changing policies and procedures from the Department

No citations issued. Exit interview conducted. A copy of the report was provided via email.
SUPERVISORS NAME:
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC809 (FAS) - (06/04)
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