565801527-11-17-2022-29-AS-KDUK-CL9SDM-20221117124723

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801527
Report Date: 11/17/2022
Date Signed: 11/17/2022 12:48:10 PM

Document Has Been Signed on 11/17/2022 12:48 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:	MOM'S PLACE 1		FACILITY NUMBER:	565801527
ADMINISTRATOR:	DMITRY BOLOTSKY		FACILITY TYPE:	740
ADDRESS:	4 MANSFIELD LANE		TELEPHONE:	(805) 383-9896
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 6	DATE:	11/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:39 AM
MET WITH:	Dmitry Bolotsky		TIME COMPLETED:	12:50 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) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 11:39AM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with staff Loida Estoque and discussed the reason for the visit. Administrator Dmitry Bolotsky arrived shortly after LPA's arrival. Entrance interview conducted

The LPA, along with Administrator, 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:

Fire extinguishers were observed to be fully charged and last serviced on 03/04/2022. Smoke detectors were tested at 12:24PM and were operable at the time of the visit.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives and sharp objects were observed to be locked in a kitchen drawer.

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, inaccessible to residents in care. The garage was observed locked and contained emergency food supply and storage.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022

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 3

Document Has Been Signed on 11/17/2022 12:48 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: MOM'S PLACE 1	FACILITY NUMBER: 565801527
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as water temperature measured at 126.0 degrees Fahrenheit in the private restroom at 11:53AM and 123.6 degrees Fahrenheit at 12:16PM in the shared hallway restroom which poses an immediate safety risk to persons in care.
	POC Due Date: 11/17/2022
	Plan of Correction
1 2 3 4	Hot water heater was adjusted during today's visit. Administrator will create a water temperature log for a 7-day period, recording temperatures in all facility restrooms at varied times of the day to ensure water temperatures are within the required range. Water temperature log will be submitted to CCL by 11/28/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 11/17/2022

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
26
27
28
29
30
31
32

BEDROOMS: The facility contains 6 total bedrooms. 1 (one) is designated as a staff room, 4 (four) are private resident rooms, and 1(one) is designated as a shared resident room. LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: The LPA observed 3 restrooms in the facility; two are shared restrooms and one is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in the private resident restroom at 11:53AM and measured at 126.0 degrees Fahrenheit. At 12:16PM, water temperature was measured in the shared hallway bathroom and measured at 123.6 degrees Fahrenheit.

INFECTION CONTROL: During today’s visit, the LPA spoke with Administrator 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. 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

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit interview conducted. Today’s reports and appeal rights were reviewed and provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3