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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850342
Report Date: 04/25/2024
Date Signed: 04/25/2024 02:01:53 PM

Document Has Been Signed on 04/25/2024 02:01 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:AMYLEW MANOR 2FACILITY NUMBER:
565850342
ADMINISTRATOR/
DIRECTOR:		SORATORIO, EMMANUELFACILITY TYPE:
735
ADDRESS:1138 MELITO DRTELEPHONE:
(805) 890-0597
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 6DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Amy Soratorio-Co AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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At 09:45 a.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. When the LPA arrived, there were one (1) staff and one (1) client present. The LPA was greeted by staff Marlene Estores and informed them of the reason for the visit. Administrator Amalia Soratorio arrived approximately at 10:20 a.m.

At 09:55 a.m., the LPA conducted a tour of the physical plant with staff to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of four (4) resident bedrooms, and two (2) bathrooms. The home is vendored by Tri-Counties Regional Center as a level 4-I home. The LPA observed fire extinguishers at the home, which were fully charged and last serviced 10/05/2023. At 10:02 a.m., all smoke alarms and carbon monoxide detectors were tested, and functioned properly. LPA observed all required postings in the living room of the home.

Kitchen: During the facility tour at 09:55 a.m., the kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects and cleaning supplies are stored in a in a locked cabinet under the sink and in an additional locked cabinet in the kitchen. Food is prepared based on a menu. Snacks and beverages are always available for residents.

Bedrooms: The LPA observed all four resident bedrooms properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.



Report will continue on LIC809-C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: AMYLEW MANOR 2
FACILITY NUMBER: 565850342
VISIT DATE: 04/25/2024
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Bathrooms: The LPA observed all restrooms to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene. At 10:10 a.m., water temperature in the resident’s room #1 restroom was measured at 119.4 degrees Fahrenheit.

Common Areas: These included the living, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. There is a fireplace in the dining room, which is covered with a screen. The facility maintained a comfortable temperature of 69 degrees. There were no obstructions and/or tripping hazards throughout the home.


The garage: The LPA observed the garage, where the emergency food and water is stored. The garage is used to store additional supplies. Additional cleaning supplies are stored in the garage in locked cabinets inaccessible to clients in care. The garage is unlocked.
Surrounding Grounds (Outdoors): The LPA did not observe a shaded area for clients. The LPA only observed a table in the back patio. The Administrator stated that they have folding chairs available for clients if they would like to be in the back patio, and that the weather damaged their umbrella and will be purchasing a new one to provide shade for the clients. There are no bodies of water on the premises.

Interviews: LPA conducted two (2) staff interviews, and one (1) client interview. No immediate concerns voiced at this time.

Record Review: At 10:56 a.m., a review of facility files was initiated. Facility records are stored in a locked cabinet in the dinning room. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 03/25/2024). The LPA obtained Client Roster, and Staff Roster. The LPA reviewed five (5) out of six (6) client files and five (5) out of ten (10) staff files. All documents reviewed appeared complete and current.

Medications: A medication audit was initiated at 12:38 p.m. and the following was observed. The medications were stored in a locked cabinet in the dining room inaccessible to the clients. Medications are labeled. During Client #1 (C1's) audit, the LPA observed medications missing medications quantity, expiration date, and number of refills on the centrally stored medication and destruction record (CSMDR). Upon observation the administrator stated the CSMDR is auto filled and provided by the pharmacy, and staff will start to review and complete if not completed accurately.



Exit interview conducted and copy of the report and appeal rights provided to Administrator Soratorio.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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