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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801527
Report Date: 11/18/2021
Date Signed: 11/18/2021 02:45:29 PM

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:MOM'S PLACE 1FACILITY NUMBER:
565801527
ADMINISTRATOR:DMITRY BOLOTSKYFACILITY TYPE:
740
ADDRESS:4 MANSFIELD LANETELEPHONE:
(805) 383-9896
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 6DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Jesse Mateo, care staffTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 1:27PM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with staff Jesse Mateo and discussed the reason for the visit. Licensee Lina Bolotsky and Administrator Dmitry Bolotsky were contacted via telephone, but were unable to be present at the facility during the visit.

The LPA, along with facility staff Jesse, 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: 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. The cabinet under the sink has an inoperable lock, however, no hazardous materials were observed to be inside the cabinet at the time of the visit. Fire extinguisher is fully charged and last serviced on 3/5/2021.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. A fireplace was observed and was adequately screened. Cleaning supplies were observed to be locked in the entry closet and properly stored at the time of the visit. The LPA observed the required postings in the common area.

The backyard has a covered outdoor area equipped with furniture for resident use. A small pond with shallow water was noted in the backyard, however it is in a fenced area inaccessible to residents. Laundry area is outside and gated. The garage was observed locked and contained emergency food supply and storage.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. 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: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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: MOM'S PLACE 1
FACILITY NUMBER: 565801527
VISIT DATE: 11/18/2021
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There are 6 (six) total bedrooms; 5 (five) are for resident use and 1 (one) is designated as a staff room.

RESTROOMS: The LPA observed 3 restrooms in the facility; two are shared restrooms and one is a private restroom. At the time of the visit, staff indicated the private restroom is closed and is inoperable. Shared resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces.

INFECTION CONTROL: During today’s visit, the LPA spoke with care staff regarding the facility’s infection control practices. Prior to entry, the facility has a central entry point for symptom screening and hand sanitization. LPA observed all staff and visitors to be wearing masks, however residents are not consistently encouraged to wear face coverings in common areas. 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. 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.


The following recommendations were made:
-N95 fit testing for all staff
- Post PINs and educate staff, residents, and families on changing policies and procedures from the Department

No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC809 (FAS) - (06/04)
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