565801620-5-20-2021-29-AS-KDUK-C37SL8-20210520135756

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801620
Report Date: 05/20/2021
Date Signed: 05/20/2021 01:59:45 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:	HICKORY HOUSE		FACILITY NUMBER:	565801620
ADMINISTRATOR:	FLORDELIZA HIPOLITO		FACILITY TYPE:	740
ADDRESS:	50 OAK ST.		TELEPHONE:	(805) 484-1115
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	36	CENSUS: 36	DATE:	05/20/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Florizelda Hipolito		TIME COMPLETED:	02:05 PM

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Licensing Program Analysts (LPAs) Kelly Dulek and Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 10:50 AM. This annual had a specific emphasis on infection control practices and procedures. The LPAs met with Administrator Flordeliza Hipolito and discussed the reason for the visit. Licensee representative Angely Morales was contacted via telephone and was unavailable during today’s visit.

The LPAs, along with Administrator Flordeliza Hipolito, toured the physical plant areas inside and outside at 10:58AM to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPAs observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 20 (twenty) total bedrooms; 4 (four) are private resident rooms and 16 (sixteen) are shared resident rooms.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPAs observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPAs observed the required postings in the common hallway. Fire extinguishes were observed to be serviced within the last year.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable 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: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

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: HICKORY HOUSE	FACILITY NUMBER: 565801620
	VISIT DATE: 05/20/2021

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and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices at 11:20AM. There are 2 (two) entries into the facility. Upon entry, the facility has a central entry point for symptom screening, however the screening area is a far distance into the middle of the facility. The facility is allowing visitors, however LPAs noted that the facility has “No Visitors” posters at the entry doors. The LPAs 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 has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:
- Best practice includes one central entry point with close proximity access to visitor screening
- Post PINs and educate staff, residents, and families on changing policies and procedures from the Department
- Visitation should be allowed per PIN 21-17.2-ASC and “No Visitor” posters should be removed

No citations were issued during today’s visit. 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: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

LIC809 (FAS) - (06/04)

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