565850272-10-10-2024-29-AS-VCOY-D9WSWJ-20241010141424

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850272
Report Date: 10/02/2024
Date Signed: 10/10/2024 02:14:36 PM

Document Has Been Signed on 10/10/2024 02:14 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SOMIS LIVING II		FACILITY NUMBER:	565850272
ADMINISTRATOR/ DIRECTOR:	CACAL, JOCELYN		FACILITY TYPE:	740
ADDRESS:	4115 SAND CANYON ROAD		TELEPHONE:	(805) 386-4145
CITY:	SOMIS	STATE: CA	ZIP CODE:	93066
CAPACITY: 4		CENSUS: 4	DATE:	10/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:50 AM
MET WITH:	Jocelyn Cacal		TIME VISIT/ INSPECTION COMPLETED:	03:30 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	At 10:40 A.M. Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced Required - 1 Year visit to the facility. Upon arrival the LPA met with Licensee, Jocelyn Cacal, the reason for the visit was explained. Entrance interview conducted. The following was noted: Facility is a single-story residence that consists of two (2) resident bedrooms and one (1) bathroom. At 11:00 A.M. the LPA conducted a tour of the physical plant with Administrator to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Somis #2, located in the back house on the same lot as Somis #1. LPA is only conducting an annual at Somis #2. This facility doesn’t have a staff room, facility will provide 24/7 care. Fire extinguishers are fully charged and last serviced on 08/12/2024. Hardwired combination smoke detectors and carbon monoxide detectors were tested at 11:30 A.M., and all were functional at the time of the visit. No fire clearance concerns were observed. Bedrooms: There are two (2) total shared bedrooms in the facility. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. All resident rooms were observed to be furnished appropriately. Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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

FACILITY NAME: SOMIS LIVING II	FACILITY NUMBER: 565850272
	VISIT DATE: 10/02/2024

NARRATIVE

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Continued from LIC 809-C

Bathroom: The LPA observed the bathroom clean, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in the bathroom. Residents have sufficient amounts of supplies for personal hygiene. The hot water was measured in the bathroom during the physical plant tour. At 11:23 A.M. hot water measured 118.2 Fahrenheit. Cleaning supplies are located in a locked cabinet under the kitchen sink.

Common Areas: In the common areas, including dining room and living room, walls and flooring were checked for cleanliness and good condition. At the time of the visit, furniture was observed to be in good condition. LPA observed the fireplace in the living room, which was adequately screened. Facility maintained a comfortable temperature of 74 degrees. LPA observed all required postings in the living area. At the entrance of the hallway, there are two (2) closets. Closet #1, located on the left, is locked and used by the facility to store hygiene products for all residents, as well as a First Aid Kit and manual. Closet #2, on the right, contains PPE, toilet paper, emergency water and other paper supplies. Additionally, near Room#2, LPA observed a locked closet housing a washing machine. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit.

Kitchen: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food as well as emergency food. Knives and sharps are locked in a separate kitchen drawer to the left of the kitchen sink. LPA observed them to be locked and properly stored at the time of the visit. At 11:12 A.M. hot water temperature measured at 116.8 degrees Fahrenheit.

Surrounding Grounds (Outdoors): The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises at the time of the visit.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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

FACILITY NAME: SOMIS LIVING II	FACILITY NUMBER: 565850272
	VISIT DATE: 10/02/2024

NARRATIVE

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Continued from LIC 809-C

Record Review: Between 12:05 P.M. and 1:55 P.M. a review of facility files was initiated. Staff records are kept at Somis 1, main house located on the same lot. Both facilities are owned and managed by the same Administrator. The LPA reviewed all four (4) Client Files and five (5) Staff records. All documents reviewed appeared complete and current.

Medications: At 2:15 P.M. a medications review was initiated for all residents. Medications are centrally stored and locked in a file cabinet in the living room; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

LPA obtained Client Roster, Staff Roster, and Liability insurance. Last emergency drill was conducted on 07/28/2024.

Interviews: At 3:00 P.M. the LPA conducted two (2) staff Interviews. The LPA was not able to interview any residents due to two (2) residents are non-verbal, one (1) was asleep and one (1) did not want to be interviewed.

No deficiencies cited. Exit interview conducted. A copy of today's report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC809 (FAS) - (06/04)

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