565802444-7-28-2022-29-AS-MARO-CGS45H-20220728184757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802444
Report Date: 07/28/2022
Date Signed: 07/28/2022 06:48:34 PM

Document Has Been Signed on 07/28/2022 06:48 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:	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:	07/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	05:00 PM
MET WITH:	Roxana Lara		TIME COMPLETED:	06:50 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 5:00 p.m. The last annual conducted at this facility was on 8/05/2021. This annual has a specific emphasis on infection control practices and procedures. The LPA was greeted and scanned at the door by Staff, Mark. The Administrator, Roxy arrived shortly after and was explained the reason for the visit. Entrance interview.

At 5:05 p.m., the LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, staff room, 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 perishable and non-perishable food. The LPA observed knives and sharps in a drawer next to the stove locked and inaccessible to residents. Cleaning supplies and toxins were observed locked in the cabinet under the sink.

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 appropriate hand-washing signs were observed in the restrooms. Bathrooms were measure for hot water, at 5:07 p.m., the first bathroom measured at 106.3 degrees Fahrenheit, at 5:13 p.m., the second bathroom measured at 109.4 degrees Fahrenheit, and at 5:18 p.m., the third bathroom was measured at 105.8 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: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: 07/28/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

...Continued from LIC 809...

GARAGE AND GROUNDS: The garage is locked and attached to the house. Cleaning supplies and chemicals were observed to be stored and inaccessible to residents in care. There is one (1) additional refrigerator in the garage with perishable items in good condition. There is a covered patio area with patio furniture including several tables and chairs for resident use. Facility has two (2) fence gates that self-latch with clear passageways for emergency exit use. No large bodies of water accessible to residents 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. Medications are in a locked cabinet by the hallway. Facility temperature read at 78 degrees Fahrenheit. The LPA observed three (3) residents in the dining room having dinner during 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, and posted CDSS PINS. 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) in the garage 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.

The LPA and Administrator discussed staff vaccination requirements. All staff 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.

Exit interview conducted. No citations 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: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2