565801930-3-10-2022-29-AS-MGCZ-CCDSP6-20220310130236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801930
Report Date: 03/10/2022
Date Signed: 03/10/2022 01:04:19 PM

Document Has Been Signed on 03/10/2022 01:04 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:	NAVITA RESIDENCE YOUNG AVE		FACILITY NUMBER:	565801930
ADMINISTRATOR:	PRESEEDHA ANDICOT		FACILITY TYPE:	740
ADDRESS:	2024 YOUNG AVE		TELEPHONE:	(805) 413-2129
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	03/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Karthiga Vijayakumar		TIME COMPLETED:	01:05 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Guzman Chavez arrived at the facility unannounced to conduct a required annual visit at 10:00 a.m. The last annual conducted at this facility was on 7/07/2021. This annual has a specific emphasis on infection control practices and procedures. The LPA was greeted at the door by staff Rini Miswati. The Administrator, Karthiga Vijayakumar arrived shortly after and was explained the reason for the visit. Entrance interview.

The LPA began the physical plant tour with the Administrator of the common areas, laundry room, kitchen area, resident bedrooms, staff room, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

At 11:25 a.m., the LPA identified an individual that has been working at the facility for about a week and is not associated with the facility. After confirmation, during the plant tour, the Administrator had I1 leave the facility immediately.

COMMON SPACES: The living room area is clean and properly furnished with seating, a table, a television, and two reclining chairs for resident use. The LPA observed three residents in the living room during time of visit.

KITCHEN: The LPA observed the kitchen/dining area to be clean and kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The LPA observed the knives and sharps to be stored in a locked cabinet in the kitchen island locked and inaccessible to residents. Medications are in a locked cabinet adjacent to the kitchen.

LAUNDRY ROOM: The LPA observed two cabinets designated for cleaning supplies locked and inaccessible to residents. ...Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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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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: NAVITA RESIDENCE YOUNG AVE	FACILITY NUMBER: 565801930
	VISIT DATE: 03/10/2022

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…Continued from LIC 809...

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. The LPA observed three bathrooms for resident use. The first bathroom measured at 111.2 degrees Fahrenheit, the second bathroom measured at 105.4 degrees Fahrenheit, and the third bathroom measured at 105.8 degrees Fahrenheit

GARAGE AND GROUNDS: The garage is locked and attached to the house. Cleaning supplies and chemicals are stored and inaccessible to residents. There is one (1) additional refrigerator in the garage with perishable items in good condition. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has one fence gate that self-latches with a clear passageway for emergency exit use. The LPA observed no large bodies of water accessible to residents.

During today’s visit, the LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE). Staff were observed wearing face coverings. All staff and residents are fully vaccinated and boosted. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are ad

equate.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Civil penalties assessed in the amount of $500.00.

Exit interview conducted. Appeal rights were discussed. A copy of the report and appeal rights provided to Administrator via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/10/2022 01:04 PM - It Cannot Be Edited

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: NAVITA RESIDENCE YOUNG AVE	FACILITY NUMBER: 565801930
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2) Request a transfer of a criminal record clearance… This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA interviews, the licensee did not comply with the section cited above as I1 does not a criminal record clearance and has worked at the facility for over 5 days which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2022
	Plan of Correction
1 2 3 4	The Administrator had I1 leave the facility immediately and has agreed to have them be associated with the facility with a background clearance by 3/16/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC809 (FAS) - (06/04)

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