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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850269
Report Date: 06/07/2022
Date Signed: 06/07/2022 05:20:24 PM


Document Has Been Signed on 06/07/2022 05:20 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:KINDCARE SENIOR HOMEFACILITY NUMBER:
565850269
ADMINISTRATOR:HERNANDEZ, VICTORFACILITY TYPE:
740
ADDRESS:4810 JUSTIN WAYTELEPHONE:
(323) 236-9397
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:6CENSUS: 0DATE:
06/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Victor HernandezTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Victor Hernandez at 10:19 AM. This is a change of ownership application and the facility is currently licensed as Ron and Tess Home Care LLC, 567609979. A Dementia program was included in the plan of operation. A Hospice Waiver for six has been requested. Component III was completed with the applicant during the inspection.

The facility is a single story. At 10:23 AM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for five (5) non-ambulatory residents and one (1) bedridden resident in bedroom #2. The facility has two private resident bedrooms, bedroom # 2 and bedroom # 3, and two shared bedrooms, bedroom #1 and bedroom #4.. Bedroom #2 has a direct exit outside. All resident bedrooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is no staff room so the facility will have awake night staff only. All rooms were free of odors. All window screens were clean and maintained in good repair.
There are two restroom for resident use. There is one restroom located in the common hallway and one private restroom in bedroom #4. The resident restrooms have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in both bathrooms and measured between 105.8 and 108.1 degrees F.

Resident and staff records, first aid supplies, and medications are centrally stored in locked filing cabinet which is currently located in Family room. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. Report continued on LIC 809-C.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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 3


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: KINDCARE SENIOR HOME
FACILITY NUMBER: 565850269
VISIT DATE: 06/07/2022
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The kitchen and dining area was observed. The kitchen area has a divider for safety purposes. Kitchen knives are stored in a locked drawer in the kitchen. Stove burners are rendered inaccessible to the residents by the use of knob locks. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located in under the kitchen sink and in a locked cabinet in the garage. No flies or other vermin were observed. The hot water temperature measured at 111.2 degrees F.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and family room. There was sufficient space to accommodate both indoor and outdoor activities. A night light is maintained in hallway. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have a portable air conditioning unit to cool the rooms to a comfortable range, not to exceed 85 degrees F.

The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There is one fire extinguisher in the house. It is fully charged and last serviced on 01/20/2022. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a locked hallway cabinet. Extra incontinence supplies are stored in garage. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in the dining room. The emergency telephone numbers are posted in entryway. Other required postings are posted in the entryway and family room area.

Continued on LIC 809-C.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: KINDCARE SENIOR HOME
FACILITY NUMBER: 565850269
VISIT DATE: 06/07/2022
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The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. The entire property is fenced. The back and sides of the house are separated from the front yard by self-latching gate. There are two locked storage sheds in the back yard. There are not any open bodies of water on the premises at the present time.
The garage has locked storage for items that could pose a danger to residents.

Pre-Licensing is complete and this facility has no deficiencies. This report will be sent to the Centralized Application Bureau (CAB) once all corrections are received. 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.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3