565801482-5-21-2022-29-AS-EPEI-CEMTPK-20220521145427

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801482
Report Date: 05/21/2022
Date Signed: 05/21/2022 02:55:24 PM

Document Has Been Signed on 05/21/2022 02:55 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:	VIA ESMERALDA L.L.C.		FACILITY NUMBER:	565801482
ADMINISTRATOR:	ESMERALDA OCAMPO-NUNEZ		FACILITY TYPE:	740
ADDRESS:	3521 EAST ELMA ST.		TELEPHONE:	(805) 216-6195
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 2	DATE:	05/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:18 PM
MET WITH:	Esmeralda Ocampo-Nunez, Licensee		TIME COMPLETED:	03:00 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) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 12:18 p.m., LPA was greeted by the Licensee, Esmeralda Ocampo-Nunez. This annual had a specific emphasis on infection control practices and procedures. At 12:44 p.m., the LPA, along with the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. At 12:49 p.m., the LPA observed one of the staff room, which is currently under construction/ remodeling. At 1:45 p.m., the LPA and the Licensee had a conversation with the Licensing Program Manager (LPM) Kristin Heffernan, regarding the staff room being under construction/ remodeling. The staff room has a restroom, but it is not in the current facility sketch. The Licensee will update the facility sketch and send the sketch to the Department. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 12:58 p.m., hot water measured at 111.5-degree Fahrenheit. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguishers to be fully charged and last serviced on 12/14/2021. Flashlights were observed throughout the facility. Upon entry, signs are posted to promote handwashing, cough/sneeze etiquette, and physical distancing. At 12:54 p.m., fire alarms and carbon monoxide detectors were tested and functioned properly. The temperature was maintained at a comfortable level. Cleaning supplies and disinfectants are stored in the locked laundry room. Medications and first aid kits are located in a locked file cabinet near the laundry room. The LPA observed cameras in the common areas, as well as the backyard. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2022

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: VIA ESMERALDA L.L.C.	FACILITY NUMBER: 565801482
	VISIT DATE: 05/21/2022

NARRATIVE

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KITCHEN: At 12:57 p.m., the LPA observed the kitchen/dining area. Knives and sharp items are stored in a locked shed in the backyard. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 12:57 p.m., hot water measured at 112.1-degree Fahrenheit.

OUTDOOR SPACE: At 1:00 p.m., the LPA observed the backyard, which has a covered outdoor area for resident use. There are no open bodies of water. The garage is locked and attached to the house.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee regarding the facility’s infection control practices. LPA observed a 30-day supply of Personal Protection 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 has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were observed at this time. Exit interview conducted with the Licensee. Report issued and a copy of the report was emailed to the Licensee.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2022

LIC809 (FAS) - (06/04)

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