565802458-11-14-2023-29-AS-ECOZ-CXL2FX-20231114162215

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802458
Report Date: 11/14/2023
Date Signed: 11/14/2023 04:22:49 PM

Document Has Been Signed on 11/14/2023 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ROWE RESIDENCE		FACILITY NUMBER:	565802458
ADMINISTRATOR:	ROWE, CHRISTINE		FACILITY TYPE:	740
ADDRESS:	11357 CASA STREET		TELEPHONE:	(805) 323-5034
CITY:	VENTURA	STATE: CA	ZIP CODE:	93004
CAPACITY:	6	CENSUS: 6	DATE:	11/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Christine Rowe		TIME COMPLETED:	04:30 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) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 09:50 a.m. When the LPA arrived, there were two staff and five residents present. The LPA was greeted by Caregiver Michael Asuncion and informed them of the reason for the visit. Licensee Tina Rowe shortly arrived. At 2:52 p.m. the LPA conducted a tour of the physical plant with Licensee TIna. The following was noted: Facility is a single-story residence that consists of five (5) resident bedrooms and three (3) bathrooms. The LPA observed (1) fully charged fire extinguisher and last serviced on April 28, 2023. All smoke alarms and carbon monoxide detectors were tested and functioned properly during time of visit. LPA observed all required postings in the entrance of the home. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; Sharp objects are stored in a locked box in a drawer to the left of the stove. Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: LPA observed all bathrooms clean, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. At 03:04 p.m. water temperature in resident’s restroom was measured at 112.1 degrees Fahrenheit. Report will continue on LIC809-C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023

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 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROWE RESIDENCE	FACILITY NUMBER: 565802458
	VISIT DATE: 11/14/2023

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

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the living room, which is covered with a screen. The facility maintained a comfortable temperature of 76 degrees.

Garage: The garage is where the washer and dryer are held, including additional non-perishable emergency food and water. Cleaning supplies and disinfectants are kept in locked cabinets in the garage.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

File review: At 12:15 p.m. a review of facility files was initiated, and the following was observed.
The LPA reviewed five (5) of six (6) resident files. All documents reviewed appeared complete and current. The LPA reviewed five (5) out of eleven (11) staff files. All documents reviewed appeared complete and current. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 10/5/2023). The LPA obtained Client Roster, Staff Roster, and copy of the insurance liability.

Interviews: At 3:12 p.m. the LPA initiated interviews. The LPA conducted two (2) staff and two (2) resident Interviews. No immediate concerns voiced during the visit.

Medication audit: Medications review began at 02:05 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.

Exit interview conducted and copy of the report provided to Licensee Tina.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5