565850281-11-8-2022-29-AS-AASO-CKYL73-20221108072939

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850281
Report Date: 11/07/2022
Date Signed: 11/08/2022 07:31:45 AM

Document Has Been Signed on 11/08/2022 07:31 AM - 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:	NAVITA RESIDENCES TULL		FACILITY NUMBER:	565850281
ADMINISTRATOR:	VIJAYAKUMAR, KARTHIGA		FACILITY TYPE:	740
ADDRESS:	5603 TULL ST		TELEPHONE:	(805) 494-4121
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	6	CENSUS: 6	DATE:	11/07/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:04 PM
MET WITH:	Karthiga Vijayakumar		TIME COMPLETED:	04:15 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) Angel Ascencio conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Karthiga Vijayakumar. This is a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver has been requested and approved. The facility is a one story facility. At 2:06 p.m., 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 residents. The bedridden room is located Room #2. The facility has six (6) private resident bedrooms. Only Room #2 has direct exit to the outside. All resident rooms are set up with beds, nightstands, 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 are no staff rooms – awake night staff only. All rooms were free of odors. All window screens were clean and maintained in good repair. There are three (3) bathrooms in the home. One (1) is designated as a staff bathroom. The resident bathroom(s) have a shower with non-skid materials. The toilet and shower have grab bars. The master bathroom has a shower and bathtub located near Bedroom #2. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105F and 120F. Resident and staff records are stored in the cabinet which is currently located in a locked closet in the kitchen. Medications are centrally stored in a locked cabinet in the kitchen. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in the kitchen closet. Continued on LIC 809 - C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

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: NAVITA RESIDENCES TULL	FACILITY NUMBER: 565850281
	VISIT DATE: 11/07/2022

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 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 the garage. No flies or other vermin were observed.

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 dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is a fireplace in the living room. It is screened and there are no tools. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant not 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. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There are 2 fire extinguishers throughout the house. They are fully charged and do not exceed the expiration date. Hot water was tested in each bathroom, which included the resident bathroom(s) and any common bathrooms. The laundry area is located in the Laundry Room. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a closet in the hallway. Extra incontinence supplies are stored in the hallway. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in the office area. Other required postings are posted in the office area.

Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

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: NAVITA RESIDENCES TULL	FACILITY NUMBER: 565850281
	VISIT DATE: 11/07/2022

NARRATIVE

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The exterior passageways were clean and clear of any obstructions. There is an umbrella, 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 gate at the West side passageway. There is a door with a gate with a self-latching mechanism for persons to enter the front yard. There are no other structures on the property. There are no bodies of water on the premises at the present time. The garage is accessible from the house; the doors were locked.

The following items must be corrected prior to licensure.

- Coordinate with Hospice and families for the relocation of resident to bedridden room.
- Submit new facility sketch with staff room.

Submit proof of corrections, along with a copy of this report, to LPA Angel Ascencio, so that your application may be completed.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

LIC809 (FAS) - (06/04)

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