565850108-6-9-2021-29-AS-KDUK-C3TP53-20210609110005

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850108
Report Date: 06/09/2021
Date Signed: 06/09/2021 11:01:12 AM

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:	OAK PLACE RESIDENTIAL CARE		FACILITY NUMBER:	565850108
ADMINISTRATOR:	SPRING, BECKY		FACILITY TYPE:	740
ADDRESS:	50 OAK ST.		TELEPHONE:	(805) 652-0000
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	36	CENSUS: 36	DATE:	06/09/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Becky Spring		TIME COMPLETED:	11:10 AM

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 6/9/2021 at 9:20AM. This is a change of ownership application. Becky Spring will be the Administrator for the proposed facility and was present during today’s visit. Also present during today’s visit were licensee representatives Jason Meek and Rena Sepulveda, as well as Hickory House licensees Angely and Paul Morales. A tour of the facility was initiated at 9:22AM with the Administrator and Angely Morales. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was noted: The facility consists of 21 (twenty one) total bedrooms – 17 (seventeen) shared rooms and 4 (four) private rooms as well as 9 (nine) total bathrooms, 8 (eight) of which are designated for client use and 1 (one) for staff use. Shared facility space includes a common sitting room and dining area. There is currently a total of 36 (thirty six) residents residing at the facility. Fire clearance was approved on 12/2/2020 for 36 Ambulatory only residents. LPA informed Administrator and licensee representatives that the current facility is approved for 36 total residents, 8 of which are non-Ambulatory. Licensee representatives will submit to CCL a new LIC 9054 and LIC 200, indicating a request for 8 non-Ambulatory residents. Fire extinguishers were last serviced on 8/20/2020. Fire alarms/carbon monoxide detectors were checked during the fire inspection on 12/2/2020. 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. 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: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

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: OAK PLACE RESIDENTIAL CARE	FACILITY NUMBER: 565850108
	VISIT DATE: 06/09/2021

NARRATIVE

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Cleaning supplies are stored in a locked cabinet. Knives and sharp objects are stored locked. Medication: Medication room was observed locked and contained all resident medications and active resident files. First aid supplies are available. Bedrooms: There are 21 total bedrooms in the facility. 4 are private resident bedrooms and 17 are shared resident bedrooms. All 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 8 resident 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. LPA checked water temperature in various bathrooms during the visit, all measured within regulation of 105-120 degrees F. Common Areas: These included the common seating area and dining area. 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. Surrounding Grounds (Outdoors): There were 2 shaded areas with proper furniture for outdoor use. There are no bodies of water on the premises.

In addition, during the visit for another of the licensee’s facilities on 6/8/2021, LPA JoAnn Rosales completed Component III with the licensee representatives and Administrator.

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 with Administrator. A copy of 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: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC809 (FAS) - (06/04)

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