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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802471
Report Date: 07/07/2022
Date Signed: 07/07/2022 04:37:19 PM

Document Has Been Signed on 07/07/2022 04:37 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:ARIANNA KAY HOMEFACILITY NUMBER:
565802471
ADMINISTRATOR:CAFUIR, DELIAFACILITY TYPE:
735
ADDRESS:4621 CONCORD WAYTELEPHONE:
(805) 246-8490
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 4CENSUS: 4DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:42 PM
MET WITH:Delia CafuirTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required - 1 Year Annual inspection at the facility today. Administrator Delia Cafuir arrived shortly after the inspection began. The home is vendored by Tri-Counties Regional Center as a level IV home. 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 the facility is in compliance with Title 22 Regulations. The carbon monoxide detector and smoke alarms were tested and all functioned properly. The fire extinguisher was last serviced on 04/05/22.

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

BEDROOMS: The LPA observed two single-occupancy client bedrooms and one shared client bedrooms, which were furnished appropriately with clean linens and sufficient lighting. There is one staff bedroom.

RESTROOMS: There is one common restroom for client use which was clean and sanitary and in operating condition with hand soap, paper towels, and toilet paper. The hot water measured at 114.8 degrees F.

COMMON SPACES: Living room and dining room furniture was observed to be in good condition. The LPA observed the required postings upon entry. The backyard patio is equipped with furniture for clients' use.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator 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 or testing positive for COVID. No deficiencies observed. Exit interview conducted. Report emailed to Administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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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