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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802554
Report Date: 06/27/2022
Date Signed: 06/27/2022 12:31:30 PM

Document Has Been Signed on 06/27/2022 12:31 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:E3 WELLNESS CENTERFACILITY NUMBER:
565802554
ADMINISTRATOR:MARIA MCMANUSFACILITY TYPE:
775
ADDRESS:2585-2587 TELLER ROADTELEPHONE:
(805) 375-9222
CITY:NEWBURY PARKSTATE: CAZIP CODE:
91320
CAPACITY: 45CENSUS: 15DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Marie McMmanusTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 10:45 a.m. The LPA was scanned and greeted at the door. LPA met with Administrator, Marie Mcmanus and explained the reason for the visit. Entrance interview conducted.

At 10:55 a.m., the LPA toured the physical plant with Administrator to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

There are currently 15 clients and 7 staff. The day program operates from 8:30 a.m to 12:30 p.m. Day Program currently staffs 2 clients with 1:1 and the rest with 1:3 staff to consumer ratios. The LPA observed the kitchen area to be clean and in good condition during time of visit. The refrigerator was observed with client’s lunches and snacks. The Day Program offers client’s with snacks while at the facility. There are four (4) bathroom for client use. The LPA inspected and observed restrooms to be clean, with paper towels, hand soap, and trash cans with lids. The hot water temperature was tested in four (4) restrooms, and the temperature measured between 127.4- and 129.2-degrees Fahrenheit. The Administrator had water temperature corrected during time of visit. The LPA observed several fire extinguishers throughout the facility, and they were all fully charged. Facility temperature was observed at 69 degrees Fahrenheit. The LPA observed staff actively working with clients while maintaining social distancing during a smoothie class. Facility currently does not store medication for clients.

During today’s visit, the LPA spoke with the DPM regarding the facility’s infection control practices. The facility is disinfected several times a day. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE), emergency food and emergency water. The LPA observed staff and client wearing face coverings during time of visit. All staff has been fully vaccinated.

...Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: E3 WELLNESS CENTER
FACILITY NUMBER: 565802554
VISIT DATE: 06/27/2022
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...Continued from LIC 809C...

Pursuant to Title 22, California Code of Regulations, the following deficiencies will be cited (refer to LIC 9099-D). Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. Appeal Rights discussed. A copy of this report was sent via email to Administrator.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
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Document Has Been Signed on 06/27/2022 12:31 PM - It Cannot Be Edited


Created By: Martha Arroyo On 06/27/2022 at 11:58 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: E3 WELLNESS CENTER
FACILITY NUMBER: 565802554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above as four (4) out of four (4) facility restroom faucets delivers hot water measured at 127.4 and 129.2 degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/27/2022
Plan of Correction
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The Administrator adjusted the thermostat during time of visit and has agreed to submit a hot water temperature log for seven (7) days to show that the hot water is being maintained between temperatures 105- and 120-degrees Fahrenheit and submit to CCL by 7/05/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022


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