565850073-10-15-2020-29-AS-KDUK-BUEW3A-20201015165536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850073
Report Date: 10/15/2020
Date Signed: 10/15/2020 04:56:15 PM

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:	OCEAN BREEZE AT BLUE OAK		FACILITY NUMBER:	565850073
ADMINISTRATOR:	KATAPODY, GEORGIA		FACILITY TYPE:	740
ADDRESS:	1132 BLUE OAK ST		TELEPHONE:	(805) 482-7082
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS:	DATE:	10/15/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Dania Fayyad		TIME COMPLETED:	01:31 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) Kelly Dulek conducted a pre-licensing inspection for this proposed facility on 10/15/2020 at 12:05pm. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted virtually with the use of "FaceTime" with applicant representative Dania Fayyad. In addition, the residential care facility for the elderly (RCFE) inspection tool was not used during today’s inspection. This is a change of ownership application, but the facility name will remain the same. Georgia Katapody is the current administrator and was also present during the virtual visit. A virtual tour of the facility was initiated at 12:10pm with the licensee representative. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was noted: The facility consists of 6 bedrooms – one designated for live-in staff use and 5 for resident use as well as 3 bathrooms. Shared facility space includes a common living room, dining area, and family room. There is currently a total of 6 residents residing at the facility. Fire clearance was approved on 08/25/2020 for 6 Non-ambulatory residents. Hardwired smoke detector/carbon monoxide detectors as well as 2 fire doors were checked at 12:34pm and functioned properly during time of visit. Fire extinguishers were last serviced on 06/12/2020. LPA observed all required postings on the wall in the main hallway/entryway. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Per administrator, the administrator purchases a large supply of food every two weeks, with periodic smaller grocery purchases in-between. Cleaning supplies are stored under the sink in a locked cabinet. Knives and sharp objects are in a locked drawer. Medication: Medications and resident files are stored in a locked Report Continued on LIC809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020

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: OCEAN BREEZE AT BLUE OAK	FACILITY NUMBER: 565850073
	VISIT DATE: 10/15/2020

NARRATIVE

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kitchen cabinet. First aid supplies available. Bedrooms: There are 6 total bedrooms in the facility. One is for staff use, 4 are private resident bedrooms and one is a shared resident bedroom. All 5 client bedrooms were checked and were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens. Bathrooms: LPA observed all 3 bathrooms were clean, properly supplied and had functional fixtures. LPA observed all bathrooms to have grab bars and non-skid mats. Residents have sufficient amounts of supplies for personal hygiene, which are stored locked. Due to the virtual nature of the visit, the hot water was unable to be measured at the time of the visit. Common Areas: These included the living room, dining area, and family room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a designated telephone available for resident use. There is a fireplace in the family room, which LPA observed to be adequately screened. There are nightlights in all common hallways/rooms providing ample lighting to common bathrooms. Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. Gates were observed to be self-closing and latching. There are no bodies of water on the premises. Garage: LPA also observed the locked garage, which contains emergency disaster supplies, locked chemical storage, an extra refrigerator/freezer and washer/dryer.

In addition, during the visit, LPA completed Component III with the licensee representative.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating under the new license until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted via telephone with administrator at 1:30pm. A copy of report was provided via email for signature.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020

LIC809 (FAS) - (06/04)

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