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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850221
Report Date: 10/12/2022
Date Signed: 10/12/2022 10:49:25 AM

Document Has Been Signed on 10/12/2022 10:49 AM - 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:GLEN PARK AT OJAIFACILITY NUMBER:
565850221
ADMINISTRATOR:RAFAEL SILVAFACILITY TYPE:
740
ADDRESS:225 N LOMITA AVETELEPHONE:
(805) 646-2402
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY: 48CENSUS: 15DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Rafael Silva/AdministratorTIME COMPLETED:
11:15 AM
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 At 8:25am on 10/12/2022, Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility unannounced. LPA was screen per current best practices infection control screening and sign in upon entrance to the facility. LPA announced who he was and the reason for the visit to the Administrator, Rafael Silva.
At 9:00am Administrator and LPA conducted a cursory tour of the facility. This facility is a 23-bedroom, 19 bathrooms with 1 kitchen, 3 common areas, a central courtyard with computer controlled delayed egress. There is a storage in the back of the facility. LPA observed at least 2 days of perishable and at least 7 days of nonperishable foods. LPA noted that the water temperature in the bathrooms were within regulation standards (95*-120*f). LPA Observed residents active in activities in the common area rooms of the facility. LPA observed fire extinguishers to be in the green and timely and properly tagged for recent service. LPA noted that the indoor fire sprinkler system was recently serviced on 09/29/2022, by R & R Fire Protection. LPA noted the facility to be clean and in good repair. LPA noted all exits and passageways were free from obstruction. LPA observed liquid soap and paper towels in the bathrooms. LPA observed hand sanitizer available throughout the facility. LPA observed a more than 30-day supply of Personal Protective Equipment (PPE) on hand at the facility storage room on the second floor. There are two bedrooms being painted and prepped for new residents and no new construction as noted from the digital file facility sketches. On this cursory tour of the facility the LPA did not observer any items that would put residents in care at risk. There were no deficiencies or citations on this cursory facility tour.

At 10:30am Administrator and LPA conducted the infection control module of the annual inspection tool. LPA noted that there were no deficiencies during the infection control module of the annual inspection.

LPA noted that the annual there were no deficiencies or citations accessed.

Exit interview, report signed, and report emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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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