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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801949
Report Date: 09/30/2022
Date Signed: 09/30/2022 01:46:41 PM


Document Has Been Signed on 09/30/2022 01:46 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:APPLEGATE @ DORADOFACILITY NUMBER:
565801949
ADMINISTRATOR:IRMA CARMONAFACILITY TYPE:
740
ADDRESS:1630 EL DORADO DRIVETELEPHONE:
(805) 207-7791
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY:6CENSUS: 6DATE:
09/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Irma CarmonaTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. The LPA met with Administrator Irma Carmona and explained the reason for the visit. The LPA toured the facility to ensure there are no health and safety hazards and to ensure regulatory compliance.

KITCHEN: Knives and chemicals are locked inaccessible. Appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The six single-occupancy resident rooms were furnished appropriately; beds had with clean linens and rooms had sufficient lighting. All direct exits were clear and no obstructions were noted. RESTROOMS: Each resident room has an en suite restroom and there is one common restroom in the hallway. Restrooms were clean and sanitary with grab bars and non-skid surfaces. At 12:53 p.m., water temperature measured at 105 F. Restrooms were fully stocked. Hand-washing signs were observed. COMMON SPACES: Smoke detectors and common monoxide detector were operable at the time of the visit. Fire extinguishers were fully charged and serviced 7/2022. All exits have functioning auditory devices. The backyard had furniture and a covered area for resident use. The side gate door was self-latching. No bodies of water noted. The garage is attached, but was locked.

INFECTION CONTROL: There was a central entry point for screening and temperature checks. The LPA was appropriately screened upon entry into the facility. Staff were wearing appropriate face coverings. Infection Control signs were observed on the front door and throughout the facility. Facility has a sufficient supply of PPE. The facility’s cleaning protocol is sufficient. Staff continue to document temperatures of staff and residents on a daily basis. There was record of staff and resident vaccinations. The LPA discussed changes around testing, visitation and vaccine requirements. The facility recently managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. The facility's procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
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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