565802471-8-29-2024-29-AS-TBYE-D8LRKD-20240829130523

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802471
Report Date: 08/29/2024
Date Signed: 08/29/2024 01:05:40 PM

Document Has Been Signed on 08/29/2024 01:05 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:	ARIANNA KAY HOME		FACILITY NUMBER:	565802471
ADMINISTRATOR/ DIRECTOR:	CAFUIR, DELIA		FACILITY TYPE:	735
ADDRESS:	4621 CONCORD WAY		TELEPHONE:	(805) 246-8490
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 4		CENSUS: 4	DATE:	08/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:45 AM
MET WITH:	Delia Cafuir		TIME VISIT/ INSPECTION COMPLETED:	01:15 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) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 10:45 AM. LPA met with facility staff who contacted facility designee Melanie Cafuir via telephone call. Facility designee arrived to the facility at 11:05 AM Entrance interview conducted and the reason for the visit was explained. Beginning at 11:05 AM, the LPA, along with facility designee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured cabinet under the sink to contain knives and cleaning supplies. The LPA observed fire extinguishers throughout the facility to be fully charged and serviced on 04/18/2024. GARAGE: LPA observed the garage to contain a washer and dryer, emergency food and water, and extra care supplies. Detergents are stored securely in locked cabinets. LPA observed an adequate amount of properly stored emergency food and water supplies. BEDROOMS: There are four (4) bedrooms in the facility; three (3) are designated for resident use, and one (1) is designated as a staff bedroom. One (1) resident room is designated as a dual occupancy room. LPA and facility designee toured all three (3) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. All resident rooms contained flashlights for emergency use. The staff room was observed to be locked and inaccessible to clients in care. Report Continued on LIC 809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

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 3

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: ARIANNA KAY HOME	FACILITY NUMBER: 565802471
	VISIT DATE: 08/29/2024

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

BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a resident restroom and one (1) is designated as a staff restroom. Bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in the resident shower and next to the resident toilet all were properly secured. The water temperature was measured in the resident bathroom at 114.6 degrees Fahrenheit which is in compliance with regulation.

COMMON AREAS: This includes the living room and dining room. LPA observed the living room to be clean and properly furnished at the time of the visit. Smoke detectors and carbon monoxide detectors were tested at 11:13 a.m. and were functional at the time of the visit. The dining room contains adequate seating for resident use. The living room contains an appropriately screened fireplace.

OUTDOOR SPACE: The facility has one (1) emergency exit gate, LPA observed clear passageways for emergency exit use. The facility has adequate shaded outdoor seating for resident use. LPA observed two (2) secured sheds to contain gardening and cleaning supplies.

RECORD REVIEW: Record review began at 11:25 a.m. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, TB tests, consent forms, and personal rights. Three (3) staff files were reviewed. All staff files contained the required documents and trainings. Four (4) resident files were reviewed. All resident files reviewed contained all required documentation. No deficiencies were observed during record review.

MEDICATION REVIEW / CASH RESOURCE REVIEW: Medication review began at 12:00 p.m. Medications are stored centrally and securely in a storage cabinet in the kitchen. Medications for two (2) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. No deficiencies were observed during medication review. Cash resources were reviewed for two (2) residents, all cash resources observed were documented properly with the corresponding receipts. No deficiencies were observed during cash resource review.
Report Continued on LIC 809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: ARIANNA KAY HOME	FACILITY NUMBER: 565802471
	VISIT DATE: 08/29/2024

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

INFECTION CONTROL / EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency disaster drill was conducted 07/14/2024. The facility’s emergency disaster plan was updated on 01/20/2024 and is adequate.

INTERVIEWS: LPA interviewed one (1) resident and two (2) staff members. The resident interviewed stated they like everything about the facility and had no concerns. The staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s updated LIC500, resident roster, surety bond, and liability insurance.

No deficiencies were cited at the time of the visit. Exit interview conducted. And a copy of the report was provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3