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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801892
Report Date: 12/16/2024
Date Signed: 12/16/2024 03:14:20 PM

Document Has Been Signed on 12/16/2024 03:14 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/
DIRECTOR:		LUIS GONZALEZFACILITY TYPE:
740
ADDRESS:827 RIVER STREETTELEPHONE:
(805) 524-5080
CITY:FILLMORESTATE: CAZIP CODE:
93015
CAPACITY: 66CENSUS: 32DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Connie SmileyTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Brian Balisi  arrived at the facility unannounced to conduct a required annual visit at 10:10 a.m. Upon arrival LPA met with Administrator Connie Smiley and Assistant Administrator Rose Gonzalez and explained the reason for the visit.
 
At approx 10:20am LPA along with Administrators , 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:
 
At approx 10:22am The LPA inspected the kitchen/food service area. Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked.
 
Between 10:22 a.m. - 11:30 a.m. the furniture in the common areas were observed to be clean and in good condition. The facility maintained a comfortable temperature. LPA observed required postings throughout the common areas.  Each stairwell was observed to have emergency evacuation chairs. There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. LPA observed eight  (8) randomly selected resident bedrooms. All resident bedrooms were furnished appropriately and had sufficient lighting. All resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured between 106.7 – 118 degrees Fahrenheit.

LPA observed appropriate outdoor furniture, with a covered shaded area for resident use. 
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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: FILLMORE COUNTRY CLUB
FACILITY NUMBER: 565801892
VISIT DATE: 12/16/2024
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Continued from 809

The facility maintained a comfortable temperature of 73 degrees. LPA observed five  (5) cameras throughout the common areas and was observed to only record video footage at this time. Facility provides sufficient space to accommodate both indoor and outdoor activities.

LPA reviewed Resident Records at 11:30 a.m. six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order at this time. LPA reviewed Personnel records at approx. 12:00 p.m. Five (05) personnel files and the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order at this time

Medications review began at approximately 01:30 p.m. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medication appeared to be given as prescribed at the time of the visit.

Interviews conducted at approx.  02:00 p.m.

Infection Control Plan / Emergency Disaster Planning: During today's visit, LPAs reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced 10/07/2024. Emergency disaster drills conducted quarterly as per regulation; the last emergency drill was conducted on 10/25/2024. Carbon Monoxide / Smoke Alarms tested on 04/04/2024 and functioned properly.

LPA obtained the following during inspection: Census, LIC 500, and copy of latest Limited Liability Insurance.
 
Exit interview conducted and a copy of report issued
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
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