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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801892
Report Date: 12/02/2022
Date Signed: 12/02/2022 04:07:59 PM


Document Has Been Signed on 12/02/2022 04:07 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:FILLMORE COUNTRY CLUBFACILITY NUMBER:
565801892
ADMINISTRATOR:LUIS GONZALEZFACILITY TYPE:
740
ADDRESS:827 RIVER STREETTELEPHONE:
(805) 524-5080
CITY:FILLMORESTATE: CAZIP CODE:
93015
CAPACITY:66CENSUS: 36DATE:
12/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Luis GonzalezTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 9:20 a.m.. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Luis Gonzalez and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The fire extinguishers were last inspected on 1/19/2022. The carbon monoxide, smoke alarms and fire suppression system were last tested 9/12/2022 by AA Technology & Electric and A&A Fire Protection; all functioned properly.

KITCHEN: The commercial kitchen was clean and appliances all appeared operable. The facility has a sufficient supply of perishable and non-perishable food as well as an emergency supply of food and water. BEDROOMS: The LPA observed ten randomly chosen rooms. Rooms were appropriately furnished, clean and had sufficient lighting. RESTROOMS: Restrooms inside the randomly chosen rooms were clean and sanitary and in operating condition. The hot water temperature averaged 108.8*F. COMMON SPACES: The lobby, activity rooms, dining room, lounge areas, theater, gym, and hair salon were all appropriately furnished and in good condition. The LPA observed the required postings throughout the facility. The patio areas in were equipped with furniture for residents' use.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. All facility staff were observed wearing masks. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID.

Exit interview conducted. A copy of the report was emailed to the Administrator.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
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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