565850271-8-16-2022-29-AS-JROS-CHCSD6-20220816134637

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850271
Report Date: 08/16/2022
Date Signed: 08/16/2022 01:47:36 PM

Document Has Been Signed on 08/16/2022 01:47 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:	SOMIS LIVING I		FACILITY NUMBER:	565850271
ADMINISTRATOR:	CACAL, JOCELYN		FACILITY TYPE:	740
ADDRESS:	4111 SAND CANYON RD		TELEPHONE:	(805) 386-4145
CITY:	SOMIS	STATE: CA	ZIP CODE:	93066
CAPACITY: 6		CENSUS: 6	DATE:	08/16/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Jocelyn Cacal		TIME COMPLETED:	01:46 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) JoAnn Rosales conducted a pre-licensing visit to the above noted facility. The LPA met with applicant Jocelyn Cacal. This is a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver for 4 has been approved. Component III was conducted in conjunction with this pre-licensing visit. The facility is a one story. A physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for 6 non-ambulatory residents of which 1 may be bedridden. The facility has 4 private resident bedrooms, Rooms #1, 2, 3, and 4 and 1 shared room, Room #5. Rooms #1 and 5 have direct exits to the outside. Room #1 is an approved bedridden room. The facility does not have fire sprinklers. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with comfortable mattress and clean linen; which includes, top and bottom linens, pillowcases, and blankets. 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 1 staff room. All rooms were free of odors. All window screens were clean and maintained in good repair. There are 2 staff bathrooms in the hallway. Their are 2 resident bathrooms with showers and non-skid mats. The toilets and showers have grab bars. The facility has 2 water heaters and the hot water tested in the resident bathrooms at 119 and 108.4 degrees F. which falls within the allowable range of 105 degrees F to 120 degrees F. Resident and staff records are stored in locked cabinets in the family room. Medications are centrally stored in a locked filing cabinet in the office. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in a hallway cabinet inaccessible to residents.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SOMIS LIVING I	FACILITY NUMBER: 565850271
	VISIT DATE: 08/16/2022

NARRATIVE

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Kitchen knives are stored in a locked drawer in the kitchen. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at 0 degrees F. and the refrigerator was maintained at 42 degrees F. The supply of 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 garage cabinet. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and activity supplies in the family room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non-private bathrooms. There is a fireplace in the family room. It is screened and there are no tools. Alarms on all exterior doors were functional at time of visit. 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 central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. There is a pull station at the front entry of the house. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There are 2 fully charged fire extinguishers throughout the house. The laundry area is located in the garage. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a hallway closet. Extra incontinence supplies are stored in the garage. There is a functioning telephone on the premises. The emergency exiting plans are located throughout the facility. The facility sketch is posted in the entryway hallway. The emergency telephone numbers are posted in entryway hallway. Other required postings are posted in the entryway hallway.

The exterior passageways were clean and clear of any obstructions. There is a shaded area in the front of the house with tables and chairs where residents can sit. The entire property is fenced. There is a driveway gate with a call box for entry. There is another house located in the back of the property which is currently

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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: SOMIS LIVING I	FACILITY NUMBER: 565850271
	VISIT DATE: 08/16/2022

NARRATIVE

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licensed as Somis Living II #565802414. There are no bodies of water on the premises at the present time. The garage is accessible from the house. There was a staff in the garage doing laundry at the time of visit. Applicant stated that they do lock the garage door.

The following item must be corrected prior to licensure. Submit proof of corrections, along with a copy of this report, to LPA JoAnn Rosales, so that your application may be completed: Photo of refrigerator temperature reading at 40 degrees F. or less.

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.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC809 (FAS) - (06/04)

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