565801482-5-30-2024-29-AS-TCAA-D5RL2S-20240530082249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801482
Report Date: 05/29/2024
Date Signed: 05/30/2024 08:23:36 AM

Document Has Been Signed on 05/30/2024 08:23 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
WOODLAND HILLS N.ASC, 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: 1	DATE:	05/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Esmeralda OCampo-Nunez		TIME COMPLETED:	01:15 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) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 9:37 a.m. LPA met with licensee/administrator Esmeralda Ocampo-Nunez and explained the reason for the visit. At 9:39 a.m. LPA and 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: There are three double occupancy resident bedrooms which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The facility has two other rooms used as bedrooms by staff. The facility has a permitted accessory dwelling unit (ADU) with a separate address (3521 1/2 East Elma St.). The adults living in the facility and the ADU are all fingerprint cleared and associated to this facility. BATHROOMS: There are three bathrooms at the facility. One in the main suite which would be used by residents sharing that room. One in the hallway used by the other residents and staff. One in a staff suite which is used only by staff/ADU occupants. Bathrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. KITCHEN: The kitchen was clean. There was a sufficient supply of perishable and non-perishable food and water. Appliances appear to function properly. Knives are stored locked in a storage cabinet outside next to the outdoor kitchen. Continued on LIC 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VIA ESMERALDA L.L.C.	FACILITY NUMBER: 565801482
	VISIT DATE: 05/29/2024

NARRATIVE

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Continued from LIC 809

COMMON AREAS: LPA observed common areas, including living room, dining area, and patio to be clean and properly furnished at the time of the visit. Fire extinguishers appeared fully charged and were last serviced on 3/4/2024. Hot water temperature measured 109*F. Smoke detectors and carbon monoxide detectors were tested and functioned properly. Cleaning supplies are stored in the locked garage.

INTERVIEWS: Beginning at 10:00 a.m. LPA interviewed two staff and there were no concerns. LPA was not able to interview the one resident as the resident was sleeping.

RECORDS: LPA reviewed medications and documents for the only resident. LPA reviewed employee records and training records for four staff. There were no concerns. The emergency evacuation form was completed and updated annually. Evacuation drills are conducted monthly.

No deficiencies cited. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC809 (FAS) - (06/04)

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