565850076-10-6-2023-29-AS-KDUK-CWCUVQ-20231006155530

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850076
Report Date: 10/06/2023
Date Signed: 10/06/2023 03:55:34 PM

Document Has Been Signed on 10/06/2023 03:55 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 BEECHWOOD		FACILITY NUMBER:	565850076
ADMINISTRATOR:	RAYAS, EVEYLN		FACILITY TYPE:	740
ADDRESS:	1190 BEECHWOOD STREET		TELEPHONE:	(805) 445-6545
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 3	DATE:	10/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Evelyn Rayas		TIME COMPLETED:	04:05 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 12:45PM. LPA met with Administrator Evelyn Rayas. Entrance interview conducted. Beginning at 12:47PM, 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 01:00 PM, separate carbon monoxide detector was tested at 01:03PM 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. 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. Two (2) are designated for shared resident use and one (1) is a 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. 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 BEECHWOOD	FACILITY NUMBER: 565850076
	VISIT DATE: 10/06/2023

NARRATIVE

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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. All passageways were observed to be clear. There were no bodies of water on the premises.

RECORD REVIEW: Began at 01:14PM. 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 four (4) staff files and three (3) resident files observed were 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.

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 07/03/2023. Emergency disaster plan was observed to be complete and updated annually, as required.

MEDICATION REVIEW: Began at 02:17PM. Medications for three (3) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

INTERVIEWS: During today's visit, LPA interviewed two (2) staff and one (1) resident.

No deficiencies cited. Exit interview conducted. A copy of today's report was 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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