565850077-10-12-2021-29-AS-KDUK-C7QRMP-20211012130904

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850077
Report Date: 10/12/2021
Date Signed: 10/12/2021 01:10:05 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 BRADFORD		FACILITY NUMBER:	565850077
ADMINISTRATOR:	RAYAS, EVELYN		FACILITY TYPE:	740
ADDRESS:	17 BRADFORD AVE		TELEPHONE:	(714) 595-1286
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 2	DATE:	10/12/2021
TYPE OF VISIT:	Required - 1 Year	ANNOUNCED	TIME BEGAN:	11:38 AM
MET WITH:	Evelyn Rayas		TIME COMPLETED:	01:12 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 11:38AM. This annual had a specific emphasis on infection control practices and procedures. The LPA initially met with facility staff/designee Josefina Balanza and discussed the reason for the visit. Administrator Evelyn Rayas arrived at 12:00PM.

The LPA, along with facility Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 4 (four) are for resident use and 1 (one) is designated as a staff room.

RESTROOMS: The LPA observed 3 restrooms in the facility; two are shared restrooms and one is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage was observed locked and contained the laundry area, as well as emergency food supply, and storage.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of 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: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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 BRADFORD	FACILITY NUMBER: 565850077
	VISIT DATE: 10/12/2021

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(Continued from LIC 809)

perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff and visitors to be wearing masks, however residents are not consistently encouraged to wear face coverings in common areas. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:
- N95 fit testing for all staff
- Post PINs and educate staff, residents, and families on changing policies and procedures from the Department

No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC809 (FAS) - (06/04)

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