565802444-7-28-2023-29-AS-ECAS-CU72AP-20230728171351

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802444
Report Date: 07/28/2023
Date Signed: 07/28/2023 05:14:17 PM

Document Has Been Signed on 07/28/2023 05:14 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:	07/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	04:10 PM
MET WITH:	Administrator-Roxana Lara		TIME COMPLETED:	05:15 PM

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 4:10 p.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Roxana Lara arrived shortly thereafter.

The LPA and the Administrator 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.

BEDROOMS/BATHROOMS: Beginning at 4:15 p.m. the LPA inspected the bedroom and bathroom areas. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six designated client rooms and one staff room. Medications are located in a locked cabinet in rear hallway. The three client restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured between 105.8 and 119.8 degrees Fahrenheit in resident bathrooms.

KITCHEN: The LPA toured the kitchen/food service area. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 77 degrees F. Smoke detector(s) and carbon monoxide detector were tested at 4:35 p.m. and operational at the time of the visit. The single fire extinguisher was fully charged, and administrator will provide proof of purchase. The LPA observed required postings throughout the common space.

Continued on LIC 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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: 07/28/2023

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OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single latched. No bodies of water noted and exits are free of obstructions. The garage is where the washer and dryer are held, including additional refrigerator with perishable food items. Cleaning supplies and disinfectants are kept locked in the garage.

Due to time constraints, the LPA will return at a later date to complete the inspection.

The LPA obtained the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
- Liability Insurance

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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