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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801457
Report Date: 09/15/2022
Date Signed: 09/15/2022 04:11:23 PM

Document Has Been Signed on 09/15/2022 04:11 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:CARING HOMEFACILITY NUMBER:
565801457
ADMINISTRATOR:KARISMA G. ABRIGOFACILITY TYPE:
735
ADDRESS:655 BERKSHIRE PLACETELEPHONE:
(805) 271-9921
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 5DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Rosalia ReclusadoTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with caregiver Rosalia Reclusado and informed her of the reason for today's visit. When the LPA arrived there was one caregiver and two clients present. The other clients are currently attending their day programs. Licensee Representative Venie Gonzales was contacted at 10:50 AM and informed of the inspection. Gonzales is unable to come to the facility for the inspection, therefore, gave permission for the caregiver to sign the report.

This annual had a specific emphasis on infection control practices and procedures. The LPA 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:

KITCHEN: At 10:52 AM, the kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food and emergency water in the garage.

COMMON SPACES: All indoor and outdoor passages were free of obstruction. At the time of the visit, living room and dining room furniture was observed to be in good condition. The fire extinguisher is fully charged and last serviced on 07/06/2022. At 11:00 AM, the carbon monoxide detector and smoke detectors in the home and bedrooms were tested and were operational. Medications are locked and centrally stored in a cabinet in the hallway. There is outdoor seating for client use. Cleaning supplies are stored in a locked cabinet in the garage.

BEDROOMS: There are four client bedrooms and no staff room. 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: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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 2
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: CARING HOME
FACILITY NUMBER: 565801457
VISIT DATE: 09/15/2022
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RESTROOMS: The facility has one common restroom and one private restroom. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. At 10:55 AM, the hot water temperature in the hallway common restroom measured at 116.6 degrees F.

INFECTION CONTROL: During today’s visit, the LPA spoke with the caregiver regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE). The facility’s cleaning protocol is sufficient. Infection control signs were posted at the entry, throughout the facility, and in the restrooms. 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.

No deficiencies cited. Exit interview and reported reviewed with the caregiver. A copy of the report was emailed to the licensee.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
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