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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802554
Report Date: 06/22/2023
Date Signed: 06/22/2023 03:24:26 PM

Document Has Been Signed on 06/22/2023 03:24 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: 28DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marie McManusTIME COMPLETED:
03:30 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 9:30am. The last annual conducted at this facility was on 06/27/2022. LPA met with the Administrator Marie McManus and the reason for the visit was explained. Entrance interview.

At 9:40am, the LPA toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted during the plant tour:

The day program operates from 8:30am to 3:00pm. The day program is currently staffed appropriately with the necessary 1:1 and 1:3 staff to consumer ratios. The facility has five colored classrooms used as activity rooms, two conference rooms, five client bathrooms, a staff room, and a kitchen area.

Common Areas: At 9:46am, 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. There are several fire extinguishers throughout the facility; they all were fully charged and were last serviced 04/13/2023. Carbon monoxide detectors are wired and operational at the time of the visit. The last fire inspection was completed in May 2023 and was found to be in compliance with Fire Code Regulations at the time of inspection. Fire and earthquake drills conducted within the last 6 months as per regulation; the last one conducted 04/10/2023. Facility temperature is kept at 67 degrees Fahrenheit. No bodies of water noted. Activities are both designed for both as individuals and as a group. The LPA observed staff interacting with clients during time of visit. No obstructions or hazards were observed inside or out. Equipment used for activities was in good condition at the time of the visit.

Report Continued on LIC 809C...
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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: E3 WELLNESS CENTER
FACILITY NUMBER: 565802554
VISIT DATE: 06/22/2023
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Report Continued from LIC 809...

Bathrooms: The LPA inspected five client (5) restrooms. Restrooms were clean and trash cans have lids to protect clients from cross contamination. The hot water temperature was tested: first bathroom measured at 109.2 degrees Fahrenheit at 9:50am; the second bathroom measured at 108.8 degrees Fahrenheit at 9:55am; the third bathroom measure at 108.1 degrees Fahrenheit at 9:57am; the fourth bathroom measured at 106.1 degrees Fahrenheit at 10:00am; and the fifth bathroom measured at 106.8 degrees Fahrenheit at 10:04am.

File Review: Records review began at 10:18 am; six (6) client records were reviewed for the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, Individual Program Plans (IPP), and current needs and services plan. All client records were in order. The LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and valid first aid/CPR. The required annual training was met for all direct care staff. All staff records were in order.



Medications: Medications review began at 2:10 pm. Medications are centrally stored and locked in a cabinet inside the staff room. Medications were labeled, stored and locked inaccessible to clients. Medications are labeled and checked for expiration dates. At 2:16 pm., the LPA observed one (1) out of three (3) medications to have dates and name written on the package. No errors found during medication audit.

At 2:00 pm, the LPA interviewed two (2) staff members.

The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, a copy of the emergency disaster plan, a copy of the surety bond, and a copy of the facility’s liability insurance.

Exit interview conducted. No citations issued. A copy of the report was provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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