565802463-9-16-2021-29-AS-MGCZ-C6WUFB-20210916153228

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802463
Report Date: 09/16/2021
Date Signed: 09/16/2021 03:33:07 PM

Document Has Been Signed on 09/16/2021 03:33 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:	PEOPLE'S CARE HOWE		FACILITY NUMBER:	565802463
ADMINISTRATOR:	POURI, KIRSTEN		FACILITY TYPE:	735
ADDRESS:	3851 HOWE RD		TELEPHONE:	(805) 398-5096
CITY:	FILLMORE	STATE: CA	ZIP CODE:	93015
CAPACITY: 6		CENSUS: 5	DATE:	09/16/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Belen Gutierrez		TIME COMPLETED:	03:30 PM

NARRATIVE

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Licensing Program Analyst (LPA), Martha Guzman Chavez conducted an unannounced visit to People’s Care Howe to conduct a Required 1-Year Annual Inspection with focus on Infection Control. This will be the first Annual for this facility. LPA was greeted and screened at the door by House Lead, Belen Gutierrez and the reason for the visit was explained. Entrance interview conducted.

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.

LPA along with Belen, initiated a tour at 12:35 pm and the following was observed:

There is a central entry point designated for universal screening for visitors by the entrance. Smoke detectors and Carbon Monoxide detector were tested and functioned properly. LPA observed two (2) Fire extinguishers to be fully charged as they were newly purchased on 12-30-2020. There is a separate small office next to the den. Next to the office, is a closet with locked file cabinets. First-Aid Kit was observed to be complete. Medications are locked and stored next to the medications. Main temperature displayed at 71 degrees Fahrenheit for the facility. LPA observed washing hands signs posted throughout facility and bathrooms. Facility has 30 day supply of emergency food and water.

OUTDOOR SPACE: LPA observed the backyard to have three (3) separate outdoor areas. Each space had shaded area with a tables and chairs for resident use. No large bodies of water on property.

KITCHEN: LPA observed the kitchen/dining area to be clean. Knives are stored in a locked cabinet next to the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food.

...(Continued on LIC 809c)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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: PEOPLE'S CARE HOWE	FACILITY NUMBER: 565802463
	VISIT DATE: 09/16/2021

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...(Continued from LIC 809)

BEDROOMS: LPA observed the resident bedrooms, which were furnished appropriately. Observed inside each room was a bed with clean linens, a nightstand, and adequate lighting. Each resident had a bedroom to themselves.

RESTROOMS: LPA observed the restrooms to be clean, sanitary and in operating condition with grab bars and non-skid mats inside the shower. There are three (3) bathrooms for resident use. Bathrooms were measure for hot water, first bathroom measured at 105.8 degrees Fahrenheit, second bathroom measured at 106.2 degrees Fahrenheit, and third bathroom measured at 105.2 degrees Fahrenheit.

LPA observed at least a 30-day supply of Personal Protection Equipment (PPE).

The facility cleans the common areas at least three times a day.

If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

LPA observed CDSS PINs posted by the entrance accessible to residents and visitors.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time.

Exit interview conducted. A copy of the report was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC809 (FAS) - (06/04)

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