565850274-8-9-2022-29-AS-KDUK-CH5TUG-20220809150218

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850274
Report Date: 08/09/2022
Date Signed: 08/09/2022 03:02:46 PM

Document Has Been Signed on 08/09/2022 03:02 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,
, CA

FACILITY NAME:	PETIT OASIS		FACILITY NUMBER:	565850274
ADMINISTRATOR:	VINCECRUZ, SUSAN		FACILITY TYPE:	740
ADDRESS:	2802 PETIT STREET		TELEPHONE:	(805) 383-8894
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY:	6	CENSUS: 0	DATE:	08/09/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:21 AM
MET WITH:	Roberto Ramirez		TIME COMPLETED:	02:05 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 inspection for this proposed facility on 08/09/2022 at 10:21AM. This is a change of ownership application, but the facility name will remain the same. Susana Vincecruz is the current Administrator and was not present at the time of the visit. LPA met with licensee representative Roberto Ramirez. A tour of the facility with facility representative was initiated at 10:25AM. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was noted: The facility consists of 3 bedrooms and 2 bathrooms. Shared facility space includes a common living room and dining area. There is currently a total of 3 residents residing at the facility. Fire clearance was approved on 05/23/2022 for a total capacity of 6 residents - 5 non-ambulatory and 1 bedridden resident. Fire extinguishers were observed fully charged and were purchased on 09/18/2021 and 05/19/2022. Fire alarms and carbon monoxide detectors were tested at 10:58AM and 11:00AM and were functional at the time of the visit. LPA observed all required postings on the wall in the entryway. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility, properly stored. Cleaning supplies are stored under the sink in a locked cabinet. Knives and sharp objects are in a locked drawer.Medication: Medications are stored in a locked cabinet. Complete first aid supplies are available. Bedrooms: There are 3 bedrooms in the facility. All 3 bedrooms are designated for shared resident use. All 3 resident bedrooms were checked and were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens. One resident Report Continued on LIC809-C

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

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: PETIT OASIS	FACILITY NUMBER: 565850274
	VISIT DATE: 08/09/2022

NARRATIVE

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bedroom contains a fireplace, which was observed to be adequately screened. Bathrooms: LPA observed 2 resident bathrooms were clean, properly supplied and had functional fixtures. LPA observed all bathrooms to have grab bars and non-skid mats. Residents have sufficient amounts of supplies for personal hygiene. Hot water was measured in both bathrooms at 113.1 degrees Fahrenheit and 112.9 degrees Fahrenheit, which is within the required range. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a designated telephone available for resident use. Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. Gates were observed to not currently be self-closing and latching. There is a swimming pool which was observed to have no water in it currently. Additionally, there is a locked gate surrounding the pool. Garage: LPA also observed the locked garage, which contains emergency disaster supplies, an extra refrigerator/freezer, washer and dryer, as well as 3 staff rooms and staff restroom.

In addition, during today's visit at 12:00PM, LPA completed Component III with the licensee representative.

The following must be completed prior to licensure:

Both gates must be self-closing and latching

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 under the new license 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 with licensee representative. A copy of report was provided via email.

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

LIC809 (FAS) - (06/04)

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