565801912-5-16-2023-29-AS-KDUK-CRVUFE-20230516153236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801912
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:33:06 PM

Document Has Been Signed on 05/16/2023 03:33 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:	MCFADDEN ASSISTED LIVING		FACILITY NUMBER:	565801912
ADMINISTRATOR:	OPHELIA MCFADDEN		FACILITY TYPE:	740
ADDRESS:	1531 DWIGHT AVENUE		TELEPHONE:	(805) 419-6617
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 6	DATE:	05/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:17 PM
MET WITH:	Ophelia McFadden		TIME COMPLETED:	03:38 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) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 1:17 PM. LPA initially met with Facility Designee Genine Coladilla. Licensee was contacted via telephone and arrived at the facility at 01:33PM. Entrance interview conducted.

The LPA, along with Facility Designee and then 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:

Carbon Monoxide detector was tested at 03:04PM, smoke detector was tested at 03:06PM and both were functional at the time of the visit.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be adequately screened. Fire extinguishers were observed to be fully charged and last serviced on 06/06/2022.

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage was observed locked and contained the laundry area, as well as emergency food supply, and storage.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean

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: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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: MCFADDEN ASSISTED LIVING	FACILITY NUMBER: 565801912
	VISIT DATE: 05/16/2023

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

linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 4 (four) are designated for private resident use and 1 (one) is designated as a shared resident room.

RESTROOMS: The LPA observed 2 (two) restrooms in the facility; one is a shared restroom and one is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in the shared resident restroom at 1:33PM and measured at 111.1 degrees Fahrenheit, which is within the required range.

RECORD REVIEW: Began at 01:40PM, staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 5 (five) resident records reviewed were complete and contained all required documents. 5 (five) staff files reviewed were complete and contained all required documents.

INFECTION CONTROL: During today’s visit, the LPA reviewed the facility’s infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate.

Due to time constraints, LPA will return at a later date to continue the inspection.

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

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2