<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801556
Report Date: 05/11/2022
Date Signed: 05/11/2022 03:28:59 PM

Document Has Been Signed on 05/11/2022 03:28 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:DOLORES FAMILY HOMEFACILITY NUMBER:
565801556
ADMINISTRATOR:REBECCA G. HERNANDEZFACILITY TYPE:
735
ADDRESS:4540 FROST DRIVETELEPHONE:
(805) 488-3947
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 4CENSUS: 3DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Jeanette GravesTIME COMPLETED:
02:20 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) KaSandra Lopez conducted an unannounced Required - 1 Year inspection at the facility today. This Required - 1 Year inspection has a specific emphasis on infection control practices and procedures. The LPA met with caregiver Jeanette Graves and explained the reason for the inspection. Licensee Representative Venie Gonzales arrived at approximately 1:30 PM but was only able to stay for a few minutes as she had an appointment to attend to.

At 1:19 PM, the LPA, along with the caregiver 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. There is currently one staff and one client present in the facility.

Kitchen The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives and items that could pose a danger were secured in locked cabinets. Medications, facility records, and PPE supplies were stored in a locked cabinet in the dining area.

Common Areas: The living room area is furnished appropriately. The fire extinguisher was fully charged and last serviced on 07/29/2021. Infection control signs are posted through out the facility. At 1:33 PM the carbon monoxide detector and smoke alarms were tested and operational. The facility has one common and one private restroom for client use. Restrooms were observed to be clean and sanitary with hand soap and paper towels. The backyard has covered seating for client use.

Bedrooms: The LPA observed the three client bedrooms. They were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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 2
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: DOLORES FAMILY HOME
FACILITY NUMBER: 565801556
VISIT DATE: 05/11/2022
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
Infection Control: During today’s visit, the LPA spoke with the caregiver regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. Infection control signs are posted in the restrooms and through out the facility. The LPA observed an adequate supply of Personal Protective Equipment (PPE). The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were cited. Exit interview and report reviewed with the caregiver. A copy of the report was emailed.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2