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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802453
Report Date: 01/20/2022
Date Signed: 01/25/2022 09:40:53 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:AT HOME CAMARILLOFACILITY NUMBER:
565802453
ADMINISTRATOR:COLON, MARGARITAFACILITY TYPE:
740
ADDRESS:417 GARDENIA AVETELEPHONE:
(805) 383-8893
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 3DATE:
01/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Margarita ColonTIME COMPLETED:
05:38 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 2:25PM. This annual had a specific emphasis on infection control practices and procedures. The LPA initially met with staff Felicidad Portugal. Licensee Margarita Colon arrived at the facility at 2:33PM. Entrance interview conducted.

Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, portions of today’s visit were conducted via telephone with the licensee Margarita Colon. The LPA, along with facility staff Felicidad Portugal, 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:

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives were observed to be locked in a kitchen cabinet. Cleaning supplies are stored in a separate locked cabinet. Fire extinguisher is fully charged.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. A fireplace was observed but is adequately screened. The LPA observed the required postings in the common area.

A locked garage contained the laundry area. The backyard has a covered outdoor area equipped with furniture for resident use.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; all 5 (five) are designated for resident use. Report Continued on LIC 809-C

SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
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: AT HOME CAMARILLO
FACILITY NUMBER: 565802453
VISIT DATE: 01/20/2022
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RESTROOMS: The LPA observed 2 restrooms in the facility. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces.

INFECTION CONTROL: During today’s visit, the LPA spoke with Licensee over the telephone regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and hand sanitization. LPA observed all staff to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.


No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC809 (FAS) - (06/04)
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