565802411-6-24-2022-29-AS-MARO-CFPQGM-20220624120945

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802411
Report Date: 06/24/2022
Date Signed: 06/24/2022 12:10:32 PM

Document Has Been Signed on 06/24/2022 12:10 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:	ANITA'S CARE VILLA		FACILITY NUMBER:	565802411
ADMINISTRATOR:	SHAFFER, JENNIFER		FACILITY TYPE:	740
ADDRESS:	521 LOUIS DRIVE		TELEPHONE:	(805) 716-3633
CITY:	NEWBURY PARK	STATE: CA	ZIP CODE:	91320
CAPACITY:	6	CENSUS: 3	DATE:	06/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jennifer Shaffer		TIME COMPLETED:	12:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 10:00 a.m. This annual has a specific emphasis on infection control practices and procedures. The last annual conducted at this facility was on 05/20/2019. The LPA was greeted at the door by staff, Cornelio. Staff called Administrator and she was explained the reason for today's visit. Entrance interview conducted.

At 10:16 a.m., the LPA began the physical plant tour with staff, Apreal of the common areas, kitchen area, resident bedrooms, bathrooms, staff room, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

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 kitchen refrigerator to be fully stocked at the time of visit. Knives and sharps are locked in a cabinet inaccessible to residents. Medications were observed in a locked cabinet in the kitchen inaccessible to resident in care.

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 two bathrooms for resident use. The first bathroom was measured at 104 degrees Fahrenheit and the second bathroom measured at 96.8 degrees Fahrenheit.

...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: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

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: ANITA'S CARE VILLA	FACILITY NUMBER: 565802411
	VISIT DATE: 06/24/2022

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...Continued from LIC 809...

COMMON SPACES: The LPA observed the living room area which is clean and properly furnished with seating, a table, and television for resident use. The fire extinguishers were fully charged and were last serviced 04/2022. All exits have functioning auditory devices. The LPA observed one (1) resident in the living room watching television during time of visit.

GARAGE AND GROUNDS: The garage is locked and attached to the house. The LPA observed a covered patio area with patio furniture including a table and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. No large bodies of water accessible to residents at the time of visit.

During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, symptoms of COVID-19, CDSS PINS, and Emergency Exit plans posted at the time of visit. 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. Staff were observed wearing face coverings. 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. 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 adequate.

Pursuant to Title 22, California Code of Regulations, the following deficiencies will be cited (refer to LIC 9099-D)

Exit interview conducted. Appeal Rights discussed. A copy of this report was sent via email to Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/24/2022 12:10 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: ANITA'S CARE VILLA	FACILITY NUMBER: 565802411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above as two (2) out of two (2) facility restroom faucets delivers hot water measured at 104 and 96.8 degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/01/2022
	Plan of Correction
1 2 3 4	The Administrator adjusted the thermostat during time of visit and has agreed to submit a hot water temperature log for seven (7) days to show that the hot water is being maintained between temperatures 105- and 120-degrees Fahrenheit.

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 Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

LIC809 (FAS) - (06/04)

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