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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802000
Report Date: 02/02/2024
Date Signed: 02/05/2024 09:41:39 AM


Document Has Been Signed on 02/05/2024 09:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:DREAM HAVEN OF SANTA PAULAFACILITY NUMBER:
565802000
ADMINISTRATOR:GRACE CATABAYFACILITY TYPE:
740
ADDRESS:404 E. MAIN STREETTELEPHONE:
(805) 420-9605
CITY:SANTA PAULASTATE: CAZIP CODE:
93060
CAPACITY:6CENSUS: 4DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Grace CatabayTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced Required 1-Year annual inspection. LPA initially met with staff and later met with the administrator Grace Catabay. LPA explained the reason for the visit.

The LPA, along with staff, 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. Smoke alarms and the carbon monoxide detector were tested and functioned properly. The fire extinguisher appeared full and was purchased on 4/22/2023.

KITCHEN/FOOD SERVICE AREA: The facility had a sufficient supply of perishable food and non-perishable food. Knives and cleaning supplies were locked in drawers and cabinets. .

COMMON AREAS: The living and dining areas are furnished appropriately. The backyard area is enclosed and outdoor activity space. Medications were locked and centrally stored in the hall closet. Cleaning supplies are stored in the locked laundry room.

BATHROOMS: There are three full bathrooms. One bathroom is used by staff, the main bathroom is in the hallway near the staff room, and one bathroom is in a resident's room. The hot water temperature was measured at 107.7*F. The bathrooms were observed to be safe and sanitary with grab bars and non-skid mats and a supply of toilet paper, soap and paper towels.

(continued on 809-C)

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: DREAM HAVEN OF SANTA PAULA
FACILITY NUMBER: 565802000
VISIT DATE: 02/02/2024
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(continued from 809)


BEDROOMS: There are six private resident bedrooms that were observed to be properly furnished, well lit and clean at the time of the visit.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening and hand sanitization. LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. To date, the facility has not had a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

INTERVIEWS: LPA interviewed three staff and one resident (other residents were not able to be interviewed). Staff responses were adequate and no concerns were voiced by resident other than they would like to go out for walks when the weather improves.



RECORDS REVIEW: LPA reviewed records for all four residents; all were complete. LPA reviewed records for four staff and the administrator; all were complete.

No deficiencies cited. Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC809 (FAS) - (06/04)
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