565802444-8-5-2021-29-AS-MGCZ-C5LQR8-20210805122330

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802444
Report Date: 08/05/2021
Date Signed: 08/05/2021 01:48:08 PM

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:	LAND OF ENCHANTMENT 1 BOARD AND CARE LLC		FACILITY NUMBER:	565802444
ADMINISTRATOR:	ROXANA LARA		FACILITY TYPE:	740
ADDRESS:	78 W GAINSBOROUGH RD		TELEPHONE:	(805) 601-5202
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	08/05/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Roxana Lara		TIME COMPLETED:	12:25 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced visit to Land of Enchantment 1 Board and Care LLC to conduct a Required Annual Inspection with focus on Infection Control. Last Annual visit was conducted on 06-26-2019. LPA was greeted and screened at the door by staff Markdel Estrada and Tiffany Sanchez Lara. Administrator Roxana Lara arrived at the facility at 9:50am and was explained the reason for the visit.

LPA 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. LPA along with Administrator Roxana, initiated a tour at 9:51am and the following was observed:

There is a central entry point designated for universal screening by the entrance. Smoke detectors and Carbon Monoxide detector were tested and functioned properly during time of visit. Fire extinguishers were observed to be fully charged. First-Aid Kit was observed by the entrance of the facility. Medications are locked in the hallway in a locked cabinet. Facility temperature read at 76 degrees Fahrenheit.

OUTDOOR SPACE: LPA observed the backyard to have a covered outdoor area with a tables and chairs for resident use. There are two (2) gates on each side of the house that have a single latch and always remains unlocked.

KITCHEN: LPA observed the kitchen/dining area to be clean. Knives are stored in a locked cabinet in the kitchen next to the oven. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

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: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

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: LAND OF ENCHANTMENT 1 BOARD AND CARE LLC	FACILITY NUMBER: 565802444
	VISIT DATE: 08/05/2021

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Continued from LIC 809

BEDROOMS: LPA observed the resident bedrooms, which were furnished appropriately. Observed inside each room was a bed with clean linens, a nightstand, and a table lamp.

RESTROOMS: LPA observed the restrooms to be clean, sanitary and in operating condition with grab bars and non-skid mats inside the shower. LPA observed signs posted in resident bathrooms and kitchen sink on washing hands and cough etiquette. Water temperature was checked in two (2) resident bathrooms and are in compliance at 105.8 degrees Fahrenheit and 107.6 degrees Fahrenheit.

LPA observed at least a 30-day supply of Personal Protection Equipment (PPE). The facility cleans the common areas at least twice daily. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

LPA did make the recommendation to the administrator to post CDSS PINs in easily accessible location for all residents and visitors.

LPA did make a recommendation to the administrator to have staff fitted for N95 masks and suggested the use of masks while in the facility.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit interview conducted, todays reports reviewed and email to administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

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: LAND OF ENCHANTMENT 1 BOARD AND CARE LLC	FACILITY NUMBER: 565802444
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above as toxic items were accessible to residents which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/06/2021
	Plan of Correction
1 2 3 4	Administrator and staff placed toxic items in inaccessible locations during facility visit. Administrator stated that they will provide documentation of staff training regarding regulation 87705(f)(2) by 8/06/21.

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: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

LIC809 (FAS) - (06/04)

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