565801528-11-22-2021-29-AS-KDUK-C8ZUYT-20211122150029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801528
Report Date: 11/22/2021
Date Signed: 11/22/2021 03:01:39 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 2		FACILITY NUMBER:	565801528
ADMINISTRATOR:	LINA BOLOTSKY		FACILITY TYPE:	740
ADDRESS:	30 LA PATERA CT.		TELEPHONE:	(805) 383-6855
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 6	DATE:	11/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:08 PM
MET WITH:	Lina Bolotsky		TIME COMPLETED:	03:05 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 1:08PM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with staff Carol Perez and discussed the reason for the visit. Licensee Lina Bolotsky arrived at the facility at 1:25PM.

The LPA, along with facility staff and licensee, 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. Kitchen refrigerator was inoperable at the time of the visit. Food had been moved to the garage refrigerators and freezers; licensee stated a technician will be present tomorrow to repair the refrigerator. Fire extinguishers are 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, both living rooms 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 laundry room 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 was noted in the backyard, however it is in a fenced area inaccessible to residents. 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: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

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 2	FACILITY NUMBER: 565801528
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2021

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as Prilosec OTC, Sudafed PE Congestion, and Severe Cough & Cold in a resident restroom/vanity which poses an immediate safety risk to persons in care.
	POC Due Date: 11/22/2021
	Plan of Correction
1 2 3 4	Items were secured to a locked location during today's visit. Administrator educated live-in and part time staff present on accessible items during the visit. POC cleared.

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: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

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 2	FACILITY NUMBER: 565801528
	VISIT DATE: 11/22/2021

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BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) total bedrooms and a Lanai; 5 (five) bedrooms are for resident use and 1 (one) is designated as a staff room.

RESTROOMS: The LPA observed 4 (four) restrooms in the facility; 3 (three) are for resident use and 1 (one) is designated for staff use. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. At 1:25PM, LPA observed Over the Counter Medications including but not limited to Prilosec, Sudafed PE Congestion, Severe Cough & Cold in a resident restroom/vanity.

INFECTION CONTROL: During today’s visit, the LPA spoke with Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and hand sanitization. Upon entry, LPA observed all 3 (three) staff and 1 (one) visitor were not 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 deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were 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: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

LIC809 (FAS) - (06/04)

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