565850097-8-30-2023-29-AS-KDUK-CV7VTD-20230830164259

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850097
Report Date: 08/30/2023
Date Signed: 08/30/2023 04:43:09 PM

Document Has Been Signed on 08/30/2023 04:43 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:	CAMARILLO HAVEN		FACILITY NUMBER:	565850097
ADMINISTRATOR:	CATABAY,ERIKA GRACE		FACILITY TYPE:	740
ADDRESS:	154 CAMINO CASTENADA		TELEPHONE:	(805) 512-0102
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 6	DATE:	08/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:38 PM
MET WITH:	Erika Catabay		TIME COMPLETED:	04:50 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 01:38PM. LPA met with facility Administrator Erika Catabay and discussed the reason for today's visit. Entrance interview conducted.

At 01:53PM, LPA, along with 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:

Fire Extinguisher was observed to be fully charged and purchased on 04/22/2023. Hardwired combination smoke detectors and carbon monoxide detector were tested at 03:58PM and were functional at the time of the visit.

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. LPA observed the fireplace in the living room, which was adequately screened. The facility laundry room and garage were observed to be locked. Garage contains emergency water supply, extra food, and storage.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. Outdoor shed was observed locked. Two (2) gates were observed to be locked, one on each side of the facility.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, as well as emergency supply. All knives and cleaning supplies were observed to be locked and properly stored 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: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

Document Has Been Signed on 08/30/2023 04:43 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: CAMARILLO HAVEN	FACILITY NUMBER: 565850097
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: 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 both outdoor gates were observed to be locked and fire clearance is approved for "latched perimiter only - no locks," therefore both locked gates poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 09/06/2023
	Plan of Correction
1 2 3 4	Gates were unlocked during today's visit. Administrator agreed to remove locks from both gates and provide proof to CCL by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: CAMARILLO HAVEN	FACILITY NUMBER: 565850097
	VISIT DATE: 08/30/2023

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
26
27
28
29
30
31
32

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; 2 (two) are designated for resident use and one is a staff restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in resident restrooms and measured within the required range.

RECORD REVIEW: Began at 02:12PM, 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. 5 (five) resident records reviewed were complete and contained all required documents. 4 (four) staff files reviewed. 3 (three) of 4 (four) staff files reviewed did not contain proof of first aid training.

MEDICATION REVIEW: Not reviewed during today's visit.

EMERGENCY DISASTER PLAN: Not reviewed during today's visit.

INFECTION CONTROL PLAN: Not reviewed during today’s visit.

INTERVIEWS: Not completed during today's visit.

Due to time constraints, LPA will return at a later date to continue the inspection.

Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted with Erika Catabay. Today’s reports and appeal rights were reviewed and provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 08/30/2023 04:43 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: CAMARILLO HAVEN	FACILITY NUMBER: 565850097
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 of 4 staff files reviewed did not contain proof of first aid training which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/13/2023
	Plan of Correction
1 2 3 4	Administrator agreed to have staff complete first aid training and will provide proof to CCL of completed training by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4