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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802451
Report Date: 11/17/2022
Date Signed: 11/17/2022 04:22:26 PM

Document Has Been Signed on 11/17/2022 04:22 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:PHOENIX8-1,LINCOLNFACILITY NUMBER:
565802451
ADMINISTRATOR:SUSANA L. MIXFACILITY TYPE:
735
ADDRESS:1900 LINCOLN CTTELEPHONE:
(805) 488-3923
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 9CENSUS: 5DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Ethel TayagTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required - 1 Year inspection at the facility today. The LPA met with staff Ethel Tayag and explained the reason for the inspection. Administrator Susie Mix was unable to come to the facility today but the LPA spoke with her on the phone and she gave permission for staff to sign the report.

This annual had a specific emphasis on infection control practices and procedures. The 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. The following was observed:

The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher was fully charged and last purchased on 03/13/2022.

KITCHEN: Knives are stored in locked cabinets. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen and the garage. Medications are stored in a locked medicine cabinet in the dining room.

BEDROOMS: The LPA observed six client bedrooms which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: There is one common restrooms and two private restrooms for client use. The restrooms were clean and sanitary with hand soap and paper towels. At 2:26 PM the hot water temperature tested in the common restroom measured at 100 degrees F. An advisory notice was issued.

COMMON SPACES: Living room and dining room furniture was observed to be in good condition. Required signs were posted. Cleaning supplies were observed to be locked in the garage and inaccessible to clients in care. The backyard has covered seating for client use.

Report continued LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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: PHOENIX8-1,LINCOLN
FACILITY NUMBER: 565802451
VISIT DATE: 11/17/2022
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INFECTION CONTROL: During today’s visit, the LPA spoke with the staff regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. All facility staff were observed wearing masks. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff are showing symptoms of COVID-19.

No deficiencies observed during the inspection. Exit interview conducted. A copy of the report was emailed to the Administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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