565850294-10-7-2022-29-AS-AASO-CJZ37E-20221007175951

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850294
Report Date: 10/07/2022
Date Signed: 10/07/2022 07:16:43 PM

Document Has Been Signed on 10/07/2022 07:16 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:	VARSITY MANOR, THE		FACILITY NUMBER:	565850294
ADMINISTRATOR:	TECSON, ALEXANDER		FACILITY TYPE:	740
ADDRESS:	4656 VARSITY ST		TELEPHONE:	(805) 402-0304
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	6	CENSUS: 4	DATE:	10/07/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Alexander Tecson		TIME COMPLETED:	01:20 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, Alexander Tecson. This is facility with a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The facility is one story home. At 09:40 a.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for two (2) non-ambulatory residents; and, four (4) bedridden residents. The facility has one (1) private resident bedroom, Room # 1 and three (3) shared room(s), Room # 2, 3, and 4. Room # 3 & 4 have direct exits to the outside. Room # 3 and 4 are bedridden rooms. 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. Room # five (5) is a designated staff room. All rooms were free of odors. All window screens were clean and maintained in good repair. There is one (1) bathroom in the hallway for all to use, and one bathroom in Room #1 for private use. All resident bathroom(s) has a shower with non-skid materials. The toilet and shower have grab bars. 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 locked cabinet closet which is currently located in the Dinning Area. Medications are centrally stored in a locked cabinet in the Dinning Area. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in a locked closet in the Dinning 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: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

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: VARSITY MANOR, THE	FACILITY NUMBER: 565850294
	VISIT DATE: 10/07/2022

NARRATIVE

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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 non-private 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 not a fireplace in the living room. Alarms on all exterior doors were engaged at the time of visit and functional. 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. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There are two (2) fire extinguishers throughout the house. They are fully charged and do not exceed the expiration date. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in the Garage. Extra incontinence supplies are stored in the Garage. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in the Hallways. The emergency telephone numbers are posted in the Kitchen. Other required postings are posted in the Hallways. 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 gates at the north and south side passageways. There is a gate with a self-latching mechanism for persons to enter the front yard. isThere are no bodies of water on the premises at the present time.
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: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

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: VARSITY MANOR, THE	FACILITY NUMBER: 565850294
	VISIT DATE: 10/07/2022

NARRATIVE

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The garage is accessible from the house; the doors were locked.

The following items must be corrected prior to licensure.

- Submit updated LIC 999 with Room #5 (Staff Room)
- Kitchen knife was accessible to residents in care
- Cleaning solutions and Disinfectant wipes were accessible to residents in care
- Various unlabeled medications were accessible to residents in care
- Centrally Stored medication cabinet was unlocked accessible to residents in care

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: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC809 (FAS) - (06/04)

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