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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801482
Report Date: 03/08/2023
Date Signed: 03/08/2023 06:25:07 PM


Document Has Been Signed on 03/08/2023 06:25 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-NUNEZFACILITY TYPE:
740
ADDRESS:3521 EAST ELMA ST.TELEPHONE:
(805) 216-6195
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 1DATE:
03/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Esmeralda OCampo-NunezTIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kelly Dulek and Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 12:16PM. LPAs were greeted by the Licensee, Esmeralda Ocampo-Nunez. Entrance interview conducted.

At 12:25PM, the LPAs, 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. The following was observed:

BEDROOMS: The LPAs observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The facility consists of 5 (five) total bedrooms, 3 (three) are designated for resident use and 2 (two) are designated for staff use. Staff bedrooms were observed locked. 1 (one) staff room has a restroom, but it is not currently permitted. The Licensee indicated she is working with a contractor who will be obtaining proper permits.

RESTROOMS: Observed beginning at 12:26PM, restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid surfaces. At 12:26PM, LPAs observed disinfecting wipes under the sink in the shared resident restroom, accessible to residents in care. At 12:30PM, hot water measured at 120.0 degrees Fahrenheit in the common resident restroom and at 12:35PM, hot water measured at 119.4 degrees Fahrenheit in the private resident restroom. At 12:35PM, LPAs observed Glade Air Freshener in the private resident restroom, accessible to residents in care.

COMMON AREAS: The LPAs observed common area to be relatively clean and properly furnished at the time of the visit. The LPAs observed the fire extinguishers to be fully charged and last serviced on 12/14/2021. During today's visit, the fire extinguishers were serviced and tags updated with the current date.
Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
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: VIA ESMERALDA L.L.C.
FACILITY NUMBER: 565801482
VISIT DATE: 03/08/2023
NARRATIVE
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At 03:55PM, 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 file cabinet near the laundry room. The LPAs observed cameras in the common areas, as well as the backyard.

KITCHEN: At 12:49PM, he LPAs observed the kitchen/dining area. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

OUTDOOR SPACE: At 12:55PM, the LPAs observed the backyard, which has a covered outdoor area for resident use. There are no bodies of water noted. Knives and sharp items are stored in a shed in the backyard. At 12:55PM, LPAs observed locks present on the shed containing sharps, however the locks were not engaged, rendering the knives accessible to residents in care. At 12:56PM, LPAs observed 2 (two) gates on both sides of the facility were not self-closing. LPAs also observed Mr. Clean disinfecting wipes on the outside patio, accessible to residents in care. The garage was locked and attached to the house.

RECORD REVIEW: Began at 01:03PM, staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 1 of 1 staff files reviewed contained all required documents. 2 additional volunteer/staff files were reviewed. Currently, the additional workers are designated as volunteers and meet volunteer requirements, however, do not meet all staff training requirements. One (1) of one (1) resident records reviewed was observed to be complete at the time of the visit.

MEDICATION REVIEW: Began at 03:13PM. Medications for one (1) of one (1) resident was observed. Prescription medications reviewed were documented and labeled in accordance with regulation. However, five (5) of five (5) over the counter medications were not labeled per regulation. Additionally, 4 (four) of 5 (five) over the counter medications (Vitamin D3, Folate, B12, and Vitamin C) did not have prescription orders.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the Licensee regarding the facility’s infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate.

Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/08/2023 06:25 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(5)(A)
Incidental Medical and Dental Care Services
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 4 (four) of 5 (five) over the counter medications for Resident #1 (R1) did not have prescription orders which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/09/2023
Plan of Correction
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Licensee agreed to contact R1's physicians by 03/09/2023 to obtain orders for R1's over the counter medications. Licensee will then provide copies of orders to CCL by 03/22/2023.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as knives and other sharps were observed in an outdoor shed which was left unlocked, which poses an immediate safety risk to persons in care.
POC Due Date: 03/08/2023
Plan of Correction
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Licensee locked the shed locks during today's visit. Licensee agreed to provide vendorized training to all staff and volunteers on section 87705 by 03/22/2023
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 03/08/2023 06:25 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as 1 (one) resident has a diagnosis of dementia, and disinfecting wipes and air freshener were observed in the resident restrooms, as well as Mr. Clean disinfecting wipes on the outside patio which poses an immediate safety risk to persons in care.
POC Due Date: 03/08/2023
Plan of Correction
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All items were secured during today's visit. Licensee agreed to provide vendorized training to all staff and volunteers on section 87705 by 03/22/2023
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 03/08/2023 06:25 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as 5 (five) of 5 (five) over the counter centrally stored medications for Resident #1 (R1) were not properly labeled, which poses a potential health and safety rights risk to persons in care.
POC Due Date: 03/22/2023
Plan of Correction
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Licensee agreed to obtain properly labeled medications for R1 and send proof to CCL by POC due date.
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 (two) of 2 (two) gates observed are not self-closing which poses/posed a potential safety risk to persons in care.
POC Due Date: 03/22/2023
Plan of Correction
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Licensee agreed to install self-closing mechanisms on both exterior gates and send proof to CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7


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: 03/08/2023
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INTERVIEWS: Beginning at 04:54PM, LPAs interviewed 2 (two) staff and 1 (one) resident.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC809 (FAS) - (06/04)
Page: 7 of 7