565850073-10-6-2023-29-AS-KDUK-CWCUPL-20231006154543

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850073
Report Date: 10/06/2023
Date Signed: 10/06/2023 03:45:54 PM

Document Has Been Signed on 10/06/2023 03:45 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:	OCEAN BREEZE AT BLUE OAK		FACILITY NUMBER:	565850073
ADMINISTRATOR:	RAYAS, EVELYN		FACILITY TYPE:	740
ADDRESS:	1132 BLUE OAK ST		TELEPHONE:	(805) 482-7082
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 5	DATE:	10/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Evelyn Rayas		TIME COMPLETED:	12:20 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 arrived at the facility unannounced to conduct a required annual visit at 08:40AM. LPA initially met with facility staff. Administrator Evelyn Rayas was contacted and arrived shortly after the visit began. Entrance interview conducted. Beginning at 09:10AM, the LPA, along with Administrator 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: Fire extinguishers are fully charged and last serviced on 05/19/2023. Hardwired combination smoke detectors and fire doors were tested at 11:03AM, separate carbon monoxide detector was tested at 11:05AM and all were functional at the time of the visit. No fire clearance concerns were observed. KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Cleaning supplies are located in a locked cabinet under the kitchen sink. Medications and sharps are locked in a separate kitchen cabinet. Water was tested in the kitchen sink and measured in the appropriate range. COMMON AREAS: This includes the living room, family room, and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. An adequately screened fireplace was noted in the living room. BATHROOMS: There are three (3) bathrooms for resident use. One (1) shared half bathroom was observed Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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: OCEAN BREEZE AT BLUE OAK	FACILITY NUMBER: 565850073
	VISIT DATE: 10/06/2023

NARRATIVE

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in the hallway, one (1) full bathroom is designated for resident use, one (1) private bathroom was observed attached to the shared resident bedroom with an adjoining door to a private resident bedroom. It was observed that the facility staff are currently using the walk-in shower for all residents, not just the residents with direct access to the private restroom. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in both shared resident bathrooms and measured in compliance with regulation.

BEDROOMS: There are six (6) total bedrooms in the facility; five (5) bedrooms are designated for resident use and one (1) staff room. The staff room is kept locked. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

GARAGE: Garage was observed locked and contained laundry area, extra food, PPE and incontinence supplies, and emergency food and water.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. Facility has one gate, which was observed at 09:25AM to be difficult to open, not self-closing or self-latching. All passageways were observed to be clear. There were no bodies of water on the premises.

RECORD REVIEW: Began at 09:30AM. 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, and personal rights. All five (5) staff files and five (5) resident files observed were observed to be in compliance with regulation. Administrator Certificate was observed to be expired 03/22/2023, however LPA reviewed the Administrator Certification website, which indicated all documents were received 02/21/2023 and the Administrator's Certificate is still pending at this time. All trainings were observed to be complete.

MEDICATION REVIEW: Began at 01:00PM. Medications for five (5) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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: 10/06/2023

NARRATIVE

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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. Emergency disaster drills are conducted quarterly, with the last drill conducted on 07/14/2023. Emergency disaster plan was observed to be complete and updated annually, as required.

INTERVIEWS: During today's visit, LPA interviewed two (2) staff and attempted to interview three (3) residents.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/06/2023 03:45 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(h)

Care of Persons with Dementia

(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as at 09:25AM, the gate was observed not self-latching or self-closing which poses a potential safety risk to persons in care.
	POC Due Date: 10/20/2023
	Plan of Correction
1 2 3 4	Administrator agreed to contact the facility's maintenance team to assist with making necessary repairs to the gate. Repairs will be completed and Administrator will provide proof to CCL by POC due date.

Type B

Section Cited

CCR

87307(a)(2)(C)

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above as facility staff utilize the walk-in shower located off a shared resident room and escort all residents through the resident room to reach the bathroom, which poses a potential personal rights risk to persons in care.
	POC Due Date: 10/20/2023
	Plan of Correction
1 2 3 4	Administrator spoke with staff during today's visit to inform them that the practice of using the private restroom for all residents needs to be discontinued. Additionally, Administrator and Licensee will come up with a plan for possible renovations in the shared resident restroom to better meet resident needs and communicate that plan and corresponding timeline to CCL by POC due date.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

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