565850217-1-14-2022-29-AS-KDUK-CANSRH-20220114130621

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850217
Report Date: 01/14/2022
Date Signed: 01/14/2022 01:07:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME:	WE CARE SENIOR FACILITY LLC		FACILITY NUMBER:	565850217
ADMINISTRATOR:	HORDAGODA, SHASHIKA		FACILITY TYPE:	740
ADDRESS:	3350 EL NIDO ST		TELEPHONE:	(818) 571-1905
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 0	DATE:	01/14/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Shashika Hordagoda		TIME COMPLETED:	09:55 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 visit to this property at 9:12am. LPA met with applicant representative Shashika Hordagoda. The applicant has obtained fire clearance for four (4) ambulatory and two (2) non-ambulatory (in bedroom #4) for a total capacity of six (6) residents. The proposed facility does not have a Dementia care plan nor pending hospice waiver at this time. Applicant completed component II interview on 12/09/2021. Today, at 10:30AM, Applicant completed component III virtually with the LPA. Beginning at 9:18 am, LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired smoke alarms and standalone carbon monoxide detector were tested and function properly at this time. Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The common living and dining areas are clean and properly furnished. A working telephone is present. There is one (1) fireplace in the residence, which had a baby gate propped in front of it. The proposed facility has four bedrooms total, any of which can be shared or for private use. Two resident bedrooms were furnished and contained beds, chairs, bedside tables and lamps. All beds have sheets, pillows, and mattress pads. There is also an ample supply of linen, towels and paper products. The proposed facility has two (2) full bathrooms for resident use. LPA observed night-lights were present in the main hallway. Hot water measured at 119.3 degrees Fahrenheit at 9:27am. The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present, as well as, a seven-day supply of water. A locked medication cabinet is located in the kitchen. There is also a locked medication box in the refrigerator. First aid kit was observed to be complete. Chemicals are stored in the locked garage. Knives were also observed in the locked garage, but Report Continued on LIC 809-C

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022

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,
, CA

FACILITY NAME: WE CARE SENIOR FACILITY LLC	FACILITY NUMBER: 565850217
	VISIT DATE: 01/14/2022

NARRATIVE

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the Applicant stated she plans to move them into a locked drawer in the kitchen. Laundry area is located in the hallway and supplies will be stored in the locked garage.

Building and grounds are free from hazard. Patio area observed outdoor shaded seating area for future resident use. The one (1) outdoor exit gate was observed to be self-closing and self-latching. The applicant was advised that any outdoor gates are not permitted to be locked.

The following needs to be completed/proof submitted prior to the facility being licensed:

1. Complaint poster (PUB 475) must be posted
2. Long-Term Care Ombudsman complaint information must be posted
3. Grab bars installed in bathrooms
4. Fireplace needs to be adequately screened

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 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 over the phone and report was issued via email for signature.

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022

LIC809 (FAS) - (06/04)

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