565850274-7-5-2023-29-AS-KDUK-CTFUU2-20230705155248

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850274
Report Date: 07/05/2023
Date Signed: 07/05/2023 03:55:58 PM

Document Has Been Signed on 07/05/2023 03:55 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:	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: 3	DATE:	07/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:12 AM
MET WITH:	Roberto Ramirez		TIME COMPLETED:	03:58 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 arrived at the facility unannounced to conduct a required annual visit at 11:12AM. LPA was greeted by facility staff Erlinda (Linda) Balaque. Licensee Roberto Ramirez was contacted via telephone and arrived at the facility at 11:32AM. Entrance interview conducted. At 12:03PM, the LPA, along with the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The facility consists of 3 (three) total bedrooms, all of which are licensed for shared resident use. RESTROOMS: The facility has 2 (two) restrooms, 1 (one) is a common restroom and the other is a private resident restroom. Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid surfaces. Hot water was measured in both resident restrooms and measured within the required range. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished at the time of the visit. The LPA observed the fire extinguishers to be fully charged and Licensee indicated both were purchased at the time of licensure in August 2022. Licensee is aware of the upcoming need to have the fire extinguishers serviced. Smoke detectors and carbon monoxide detector were tested at 12:24PM and were functional at the time of the visit. KITCHEN: The LPA observed the kitchen/dining area. Kitchen appliances are in operable condition Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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: PETIT OASIS	FACILITY NUMBER: 565850274
	VISIT DATE: 07/05/2023

NARRATIVE

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The facility has a sufficient supply of perishable and non-perishable food. Cleaning supplies and disinfectants are stored under the sink in a locked cabinet. All knives were observed to be in a locked drawer.

OUTDOOR SPACE: The LPA observed the backyard, which has a covered outdoor area for resident use. There is an outdoor pool, which was observed to be properly fenced and locked, thus inaccessible to residents in care. At 12:17PM, LPA observed the exit gate was not self-closing. The laundry area was recently relocated to outside. Licensee indicated that he will be covering the relocated laundry area.

The detached garage was observed to be locked and contained the staff living quarters, including sleeping area, refrigerator, and restroom.

RECORD REVIEW: Began at 12:24PM, staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All staff and resident files reviewed were in compliance with regulation.

MEDICATION REVIEW: Began at 01:55PM. Medications for three (3) residents were observed. Over the Counter medication for one resident was not properly labeled and Prescription label for Resident #1 (R1)'s Vitamin D3 was not printed properly by the pharmacy and was observed altered due to the pharmacy error.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. The licensee was advised to update the facility's emergency disaster plan annually.

INTERVIEWS: LPA interviewed 2 (two) staff and 3 (three) residents.

No deficiencies cited. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC809 (FAS) - (06/04)

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