565801952-12-8-2022-29-AS-MARO-CLWVDX-20221208152127

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801952
Report Date: 12/08/2022
Date Signed: 12/08/2022 03:21:52 PM

Document Has Been Signed on 12/08/2022 03:21 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 @ DRUMMOND		FACILITY NUMBER:	565801952
ADMINISTRATOR:	IRMA CARMONA		FACILITY TYPE:	740
ADDRESS:	2796 DRUMMOND PLACE		TELEPHONE:	(805) 493-9046
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	12/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Emma Carmona		TIME COMPLETED:	03:25 PM

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Licensing Program Analyst (LPA), Martha Arroyo arrived unannounced to conduct a Required 1-Year Annual Inspection with focus on Infection Control. The last annual conducted at this facility was on 10/04/2019. Upon arrival, LPA was scanned and greeted at the door by Staff, Charlene Reyes. Staff, Emma Carmona arrived shortly after and the reason for the visit was explained. LPA was advised the Administrator was in a meeting and unavailable to come to the facility. Entrance interview.

At 2:00 p.m., the LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed all knives and sharps locked in a drawer next to the range inaccessible to residents. Medication and resident files were observed in a locked closet adjacent to the kitchen.

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

RESTROOMS: There are five (5) resident restrooms. 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 appropriate hand-washing signs were observed throughout. Restrooms were measured for hot water; the water temperature is in compliance at the time of the visit as they measured between 105.1 degrees Fahrenheit and 105.8 degrees Fahrenheit.

…Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

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: APPLEGATE @ DRUMMOND	FACILITY NUMBER: 565801952
	VISIT DATE: 12/08/2022

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…Report Continued from LIC 809...

GARAGE AND BACKYARD: The garage is locked and inaccessible to residents. LPA observed the laundry room with toxins and cleaning supplies locked and inaccessible. There is another refrigerator in the garage with additional food. The LPA observed a sufficient supply of emergency water and food. Two (2) fire extinguishers were observed to be fully charged on 07/20/2022. The facility maintains at a temperature of 74 degrees. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has two (2) fence gates that self-latch with clear passageways for emergency exit use. The LPA observed a shed with paint and tools locked in the backyard inaccessible to residents in care. No bodies of water observed during time of visit.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The LPA observed two (2) residents in the living room watching television at the time of visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with Staff regarding the facility’s infection control practices. 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) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. All staff and residents are fully vaccinated and boosted. Staff were observed wearing face masks during time of the visit. No identified staffing concerns.

Exit interview conducted. No deficiencies issued. A copy of the report was provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC809 (FAS) - (06/04)

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