565850108-5-1-2023-29-AS-KDUK-CREUED-20230501153057

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850108
Report Date: 05/01/2023
Date Signed: 05/01/2023 03:32:00 PM

Document Has Been Signed on 05/01/2023 03:32 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:	OAK PLACE RESIDENTIAL CARE		FACILITY NUMBER:	565850108
ADMINISTRATOR:	SPRING, BECKY		FACILITY TYPE:	740
ADDRESS:	50 OAK ST.		TELEPHONE:	(805) 586-4086
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	36	CENSUS: 36	DATE:	05/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:08 AM
MET WITH:	Flordeliza Hipolito		TIME COMPLETED:	03:35 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 10:08AM. LPA met with facility Designee Flordeliza (Baby) Hipolito and explained the reason for today’s visit. Entrance interview conducted. Beginning at 10:25 AM, the LPA, along with the Facility Designee 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: BEDROOMS: Resident bedrooms appeared to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 20 (twenty) total bedrooms, all of which were observed during the facility tour; 4 (four) are private resident rooms and 16 (sixteen) are shared resident rooms. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPA observed sufficient amounts of soap and paper products in each restroom. Water temperature was tested in a sampling of resident restrooms, which was measured at 108.3 degrees Fahrenheit and 108.4 degrees Fahrenheit, within the required range. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be fully charged and serviced on 08/30/2022. Smoke detectors were tested during fire inspection on 01/31/2023 and were functional at that time. During today's visit, at 02:53PM, carbon monoxide detector was tested and was functional at the time of the visit. The temperature was maintained at a 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: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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: OAK PLACE RESIDENTIAL CARE	FACILITY NUMBER: 565850108
	VISIT DATE: 05/01/2023

NARRATIVE

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comfortable level throughout today's visit. Cleaning supplies and disinfectants are stored locked per regulation. The LPA observed cameras in the common areas. A working telephone is present.

KITCHEN: LPA observed the kitchen/dining area. Kitchen appliances appear to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, including emergency supply and water. Cook stated that the facility uses Sysco for their food supply and delivery takes place every Tuesday. All knives and cleaning supplies were observed to be locked and stored in compliance with regulation.

OUTDOOR SPACE: The outdoor area has 2 (two) covered outdoor seating areas equipped with furniture for resident use. An outdoor space is designated for smoking. There were no bodies of water noted.

RECORD REVIEW: Began at 11:10AM, LPA reviewed staff and resident records for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisals, and admission agreements. 5 (five) of 5 (five) staff files reviewed contained all documents. Separate training binder is maintained for all staff training. Administrator indicated all 20 hours of staff training were completed, however not all documentation was observed in the training binder. All 5 (five) of 5 (five) resident files reviewed were in compliance.

MEDICATION REVIEW: Began at 01:48PM. Medications for 5 (five) residents were reviewed. All 5 (five) of 5 (five) residents' medications were observed to be properly documented and in compliance at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA reviewed the facility’s infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate.

INTERVIEWS: Throughout today’s visit, LPAs interviewed 3 (three) staff and 3 (three) residents.

No deficiencies cited. Exit interview conducted with Facility Designee. A copy of the 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: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC809 (FAS) - (06/04)

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