565801528-11-17-2022-29-AS-KDUK-CL9VDD-20221117152034

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801528
Report Date: 11/17/2022
Date Signed: 11/17/2022 03:21:07 PM

Document Has Been Signed on 11/17/2022 03:21 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 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:	11/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:28 PM
MET WITH:	Lina Bolotsky		TIME COMPLETED:	02:55 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 1:28PM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Licensee Lina Bolotsky. Entrance interview conducted.

The LPA, along with 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:

Smoke detector was tested at 01:49PM, carbon monoxide detector was tested at 02:49PM; both were functional at the time of the visit. Fire extinguishers were observed to be fully charged and last serviced on 03/04/2022.

COMMON SPACES: The garage was observed locked and contained emergency food supply and storage. Cleaning supplies were observed to be locked in the laundry room and properly stored at the time of the visit. 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. The LPA observed the required postings in the common area.

The backyard has a covered outdoor area equipped with furniture for resident use. Empty jacuzzi and pond are located in a fenced area inaccessible to residents.

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) 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)

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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: 11/17/2022

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is designated for staff use. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in 2 (two) shared resident restrooms and measured at 118.9 degrees and 119.4 degrees Fahrenheit, which is within the required range.

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.

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. LPA observed all staff and visitors to be wearing masks at the time of the visit. 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 recommendation was made:
-N95 fit testing for all staff

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

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