565850188-10-6-2023-29-AS-ECAS-CWCUCQ-20231006152818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850188
Report Date: 10/06/2023
Date Signed: 10/06/2023 03:28:51 PM

Document Has Been Signed on 10/06/2023 03:28 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:	10/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Mervin Galvez		TIME COMPLETED:	03:40 PM

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 10:20 a.m. The LPA was greeted by staff and met with Administrator Mervin Galvez and explained the reason for the visit.

The LPA and staff 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.

BEDROOMS: The LPA began the inspection with the Bedrooms. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The facility consists of 5 (five) total bedrooms, 4 (four) are designated for resident use with (2) shared rooms and (2) two private rooms and 1 (one) designated staff room. Staff bedroom was locked appropriately.

RESTROOMS: The (2) two resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in bathrooms measured between 118.0-120.0 degrees Fahrenheit.

KITCHEN: Kitchen knives are stored locked and inaccessible in a drawer to the right of the stove. The supply of dishes is adequate. Appliances in the kitchen were clean and functional. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food.

COMMON AREAS: The facility is a single-story structure with a large sunroom, dining room and living room. The LPA did not observe any obstructions or hazards. At the time of the visit, the living room, sunroom and dining room furniture were observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 74 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The LPA observed fire extinguisher along the dining room wall which was last serviced 06/12/2023. Linen closet and locked cabinet containing cleaning supplies and hygiene items was observed in the main hallway locked and inaccessible. **Continued on LIC 809-C**

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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: 2592 CIRO LLC	FACILITY NUMBER: 565850188
	VISIT DATE: 10/06/2023

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OUTDOOR AREA: The backyard has outdoor covered patio area equipped with furniture for client use. There is a side gate for client use and is single latched. No bodies of water noted. The garage is where the washer and dryer are held, including emergency supply food items and PPE. Cleaning supplies and disinfectants are kept in in the garage. The garage is locked and inaccessible.

RECORD REVIEW: At 11:30 a.m. a review of facility files was initiated. The LPA observed documentation of Infection Control, Disaster prevention, and Insurance liability. The LPA obtained Client Roster, Staff Roster, and liability insurance.

Residents’ records review began at 11:30 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 2:15 p.m.; medications are centrally stored and locked in a mediation cabinet in the kitchen; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection 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.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

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