565801456-2-22-2023-29-AS-KDUK-CPAP5K-20230222100052

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801456
Report Date: 02/22/2023
Date Signed: 02/22/2023 10:01:33 AM

Document Has Been Signed on 02/22/2023 10:01 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:	CEDAR HOUSE		FACILITY NUMBER:	565801456
ADMINISTRATOR:	LOUISA MAE CERVANTES		FACILITY TYPE:	735
ADDRESS:	161 MARKER AVENUE		TELEPHONE:	(805) 484-0271
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY: 6		CENSUS: 6	DATE:	02/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Louisa Mae Espena		TIME COMPLETED:	10:05 AM

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 08:55AM. This annual had a specific emphasis on infection control practices and procedures. The LPA initially met with staff Lucy Irog and discussed the reason for the visit. Administrator Louisa Mae Espena arrived at the facility at 09:35AM.

The facility is vendored by Tri-Counties Regional Center as a Level III home. At 09:11AM, the LPA, along with facility staff Lucy, 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 is fully charged and last serviced 06/06/2022. Smoke detectors and carbon monoxide detectors were tested at 09:50AM and were operational at the time of the visit.

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.

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.

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.

BEDROOMS: The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 4 (four) total bedrooms; 3 (three) shared rooms are for client use and 1 (one) is designated as a staff room. Staff room was observed to be locked and empty at the time of the visit.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

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: CEDAR HOUSE	FACILITY NUMBER: 565801456
	VISIT DATE: 02/22/2023

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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. Water temperature was tested in common restroom at 09:18AM and measured at 109.8 degrees Fahrenheit, which is within the required range.

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for client use. Gates were observed to be closed and latched.

INFECTION CONTROL: During today’s visit, the LPA spoke with Administrator 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 and the one client present during today's visit to be wearing masks. 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. The facility’s policies and procedures as it pertains to infection control are adequate.

No citations issued. Exit interview conducted. A copy of the report was provided via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC809 (FAS) - (06/04)

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