565850217-2-2-2023-29-AS-KDUK-CNNVXD-20230202154923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850217
Report Date: 02/02/2023
Date Signed: 02/02/2023 03:49:41 PM

Document Has Been Signed on 02/02/2023 03:49 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:	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: 5	DATE:	02/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:07 PM
MET WITH:	Shashika Hordagoda		TIME COMPLETED:	04:00 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 12:07PM. This annual had a specific emphasis on infection control practices and procedures. Licensee Shashika Hordagoda arrived at 12:10PM. Entrance interview conducted.

The LPA, along with facility Licensee, 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. The following was observed:

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the entry way.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage was observed locked and contained emergency food supply, and separate chemical storage.

Fire extinguisher was observed to be fully charged, but last serviced 03/19/2021. The second fire extinguisher was observed to require a recharge. Smoke detectors were tested at 01:09PM and was functional at the time of the visit. Carbon monoxide detector was tested at 01:11PM and was functional at the time of the visit.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives were observed to be locked and properly stored at the time of the visit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 2 (two) are private Report 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: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

Document Has Been Signed on 02/02/2023 03:49 PM - It Cannot Be Edited

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: WE CARE SENIOR FACILITY LLC	FACILITY NUMBER: 565850217
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as water temperature measured at 129.2 degrees Fahrenheit in the common hallway restroom at 12:46PM, which poses an immediate safety risk to persons in care.
	POC Due Date: 02/10/2023
	Plan of Correction
1 2 3 4	Licensee agreed to adjust the water temperature today. Then Licensee will record water temperatures for a 7 day period at various times of the day and will provide the water temperature log to CCL by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 02/02/2023 03:49 PM - It Cannot Be Edited

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: WE CARE SENIOR FACILITY LLC	FACILITY NUMBER: 565850217
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as one fire extinguisher was fully charged, but last serviced over a year ago, and the second fire extinguisher needs recharging, which poses a potential safety risk to persons in care.
	POC Due Date: 02/16/2023
	Plan of Correction
1 2 3 4	Licensee agreed to have both fire extinguishers serviced and will provide proof of service to CCL by POC due date.

Type B

Section Cited

CCR

87705(c)(5)

(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 2 (two) out of 2 (two) residents with a diagnosis of dementia did not have a reassessment completed which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/16/2023
	Plan of Correction
1 2 3 4	Licensee will obtain the needs and service assessment from LPA. Licensee will then complete a needs and service appraisal for both dementia residents and provide proof to CCL by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: WE CARE SENIOR FACILITY LLC	FACILITY NUMBER: 565850217
	VISIT DATE: 02/02/2023

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
26
27
28
29
30
31
32

resident rooms, 2 (two) are shared resident rooms and 1 (one) is designated as a staff room.

RESTROOMS: The LPA observed 2 restrooms in the facility; one is a shared restroom and one is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was checked in resident restrooms and measured at 129.2 degrees Fahrenheit at 12:46PM in the common restroom.

RECORD REVIEW: During the visit, LPA reviewed 2 (two) resident files. Neither of the 2 resident files contained an appraisal needs and service plan and both Resident #1 (R1) and Resident #2 (R2) have a diagnosis of dementia.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff and visitors to be wearing masks. The LPA observed the facility's supply of Personal Protective Equipment (PPE), which did not contain N95 masks, gowns, or face shields. 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. To date, the facility has not had a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:
-obtain N95 masks, face shields, and gowns
- N95 fit testing for all staff

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4