<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850217
Report Date: 08/08/2024
Date Signed: 08/08/2024 01:17:14 PM


Document Has Been Signed on 08/08/2024 01:17 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 LLCFACILITY NUMBER:
565850217
ADMINISTRATOR:HORDAGODA, SHASHIKAFACILITY TYPE:
740
ADDRESS:3350 EL NIDO STTELEPHONE:
(818) 571-1905
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 5DATE:
08/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:12 AM
MET WITH:Shashika HordagodaTIME COMPLETED:
01:25 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 Analysts (LPAs) Kelly Dulek and Teresa Camara conducted a case management - deficiencies visit to address deficiencies observed during an unrelated complaint inspection at the facility today. LPAs spoke with Licensee/Administrator Shashika Hordagoda. Entrance interview conducted.

During a facility tour, which began at 08:25AM, LPAs observed 2 boxes and a plastic bag of BD Insulin Syringes on the kitchen counter. At 08:32AM, LPAs observed a knife and a pair of scissors on the kitchen counter unattended. LPAs also observed the facility's food supply, which did not contain a sufficient amount of perishable fruits, vegetables, or dairy products.

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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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 2


Document Has Been Signed on 08/08/2024 01:17 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: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/15/2024
Section Cited
CCR
87705(f)(1)

1
2
3
4
5
6
7
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
All items were secured during today's visit. Licensee agreed to provide training to staff on accessible items and provide proof to CCL by POC due date.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the above cited section, as 2 boxes and a plastic bag of syringes, a knife and scissors were found on the countertop accessible to residents, which poses an immediate safety risk to persons in care.
8
9
10
11
12
13
14
Type B
08/15/2024
Section Cited
CCR87555(b)(26)

1
2
3
4
5
6
7
87555 General Food Service Requirements (b) (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to purchase additional perishable foods in all food groups for the facility and provide proof to CCL by POC due date.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the above cited section, as the facility did not have fresh fruits or vegetables present at the facility, as well as expired and insufficient amount dairy products, which poses a potential health risk to persons in care.
8
9
10
11
12
13
14
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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2