565850242-6-27-2022-29-AS-KDUK-CFSNK3-20220627103116

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850242
Report Date: 06/24/2022
Date Signed: 06/27/2022 10:32:31 AM

Document Has Been Signed on 06/27/2022 10:32 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,
, CA

FACILITY NAME:	NAVITA RESIDENCES EDGEMONT		FACILITY NUMBER:	565850242
ADMINISTRATOR:	VIJAYAKUMAR, KARTHIGA		FACILITY TYPE:	740
ADDRESS:	1690 EDGEMONT DR		TELEPHONE:	(805) 413-2455
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 0	DATE:	06/24/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:44 PM
MET WITH:	Shamin Noor Mohamed		TIME COMPLETED:	05:45 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 conducted a pre-licensing visit to this property at 1:44PM. LPA met with applicant representatives Shamin Noor Mohamed and Shila Pandey as well as Administrator Karthiga Vijayakumar. This is a Change of Ownership application and the current facility has residents in care. The applicant has obtained fire clearance for five (5) non-ambulatory and one (1) bedridden (in bedroom #7) for a total capacity of six (6) residents. The proposed facility does have a Dementia care plan as well as a pending hospice waiver for two (2) residents. Applicant completed component II interview on 05/17/2022. Today, at 3:21PM, Applicant representatives and Administrator completed component III with the LPA. Beginning at 01:45PM, 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 at 02:07PM and function properly at this time. Fire extinguisher was observed to be fully charged and purchased on 03/10/2022. Bedrooms: The proposed facility has seven (7) bedrooms total, one (1) of which is designated for staff use and six (6) are private resident rooms. All 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. Restrooms: The proposed facility has three (3) full bathrooms for resident use; two (2) are shared restrooms and one (1) is designated as a private restroom. LPA observed night-lights were present in the main hallway. All restrooms contained grab bars and non-skid mats. Hot water was measured in the two (2) shared restrooms and measured within the required 105 degrees Fahrenheit to 120 degrees Fahrenheit. Report Continued on LIC 809-C

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

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: NAVITA RESIDENCES EDGEMONT	FACILITY NUMBER: 565850242
	VISIT DATE: 06/24/2022

NARRATIVE

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Common Areas: 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 was properly screened at the time of the visit. Chemicals are stored in the locked garage. Laundry area, including all laundry supplies, is located in the locked garage. Building and grounds are free from hazard. Patio area observed outdoor shaded seating area for 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.

Kitchen: 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 two-day supply of perishable foods and a seven-day supply of water. Knives are stored in a locked cabinet. A locked medication cabinet is located just outside the kitchen. There is also a locked medication box in the refrigerator. First aid kit was observed to be complete.

The following needs clarification prior to license being issued:

Fire clearance clarification - room(s) designated for bedridden use

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 and a copy of the report was provided via email.

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

LIC809 (FAS) - (06/04)

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