565850188-10-14-2022-29-AS-MARO-CK7TNE-20221014145238

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850188
Report Date: 10/14/2022
Date Signed: 10/14/2022 02:53:08 PM

Document Has Been Signed on 10/14/2022 02:53 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:	2592 CIRO LLC		FACILITY NUMBER:	565850188
ADMINISTRATOR:	SARREAL, JOVY		FACILITY TYPE:	740
ADDRESS:	2592 CIRO AVE		TELEPHONE:	(805) 807-0663
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	10/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Mervin Galvez		TIME COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA), Martha Arroyo arrived unannounced to conduct a Required 1-Year Annual Inspection with focus on Infection Control at 12:45 p.m. This will be the first annual since their Pre-Licensing visit on 9/24/2021. Upon arrival, LPA was scanned and greeted at the door by staff, Rosalinda and Rolando. The Licensee, Gilliana Sherman and Administrator, Mervin Galvez arrived shortly after and the reason for the visit was explained. Entrance interview.

At 1:20 p.m., the LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, bathroom, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed all knives and sharps locked in a drawer next to the oven inaccessible to residents. Cleaning supplies and toxins were observed locked under the kitchen sink. Medication and facility files were observed in a locked cabinet adjacent to the kitchen.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. The appropriate hand-washing signs were observed throughout. The bathrooms were measured for hot water; the first bathroom measured at 105.8 degrees Fahrenheit at 1:25 p.m., and the second bathroom measured at 105.3 degrees Fahrenheit at 1:27 p.m.

…Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

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: 2592 CIRO LLC	FACILITY NUMBER: 565850188
	VISIT DATE: 10/14/2022

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…Report Continued from LIC 809...

GARAGE AND GROUNDS: The garage is locked and attached to the house. There is another refrigerator in the garage with additional food. The LPA observed a sufficient supply of emergency water and food. The fire extinguisher was observed to be fully charged on 6/07/2022. The facility maintains at a temperature of 75 degrees. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has two (2) fence gates that self-latch with clear passageways for emergency exit use. No large bodies of water accessible to residents at the time of visit.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The LPA observed two (2) residents in the living room watching television at the time of visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. All staff and residents are fully vaccinated and boosted. Staff were observed wearing face masks. No identified staffing concerns.

Exit interview conducted. No citations issued. A copy of the report was provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

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