565850346-5-13-2024-29-AS-TCAA-D58UXH-20240513155823

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850346
Report Date: 05/13/2024
Date Signed: 05/13/2024 03:58:58 PM

Document Has Been Signed on 05/13/2024 03:58 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:	MOM'S PLACE I		FACILITY NUMBER:	565850346
ADMINISTRATOR:	YUSUF, IBIRONKE		FACILITY TYPE:	740
ADDRESS:	4 MANSFIELD LANE		TELEPHONE:	(818) 274-1809
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 0	DATE:	05/13/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:33 PM
MET WITH:	Laila Kulungu		TIME COMPLETED:	04:15 PM

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Licensing Program Analyst (LPA) Teresa Camara conducted an announced pre-licensing visit to this property at 1:30 p.m. LPA met with applicant representative/facility designee Laila Kulungu. This application is for a Change of Ownership Application (CHOW) and the current licensed facility has six residents in care. The applicant has obtained fire clearance for a total capacity of six non-ambulatory residents, one of which may be bedridden. The pending facility has a Dementia care plan. Applicant completed the component II interview on 09/21/2023. During today's visit, the facility designee completed component III with the LPA.

Beginning at 1:35 p.m., LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired combination smoke alarm and carbon monoxide detectors were tested and function properly. Sprinkler system was tested during the fire inspection on 4/11/2024 and functioned properly. Fire extinguisher was observed to be fully charged and purchased on 11/10/2023. Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The living room and dining area are clean and properly furnished. A properly screened two-sided fireplace was observed in the dining room and living room. A working telephone is present.

The proposed facility has five (5) bedrooms total; one bedroom is shared and the rest are private. The den is used as a staff room and remains locked. All resident bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have appropriate linens. There is also an ample supply of linen, towels and paper products. LPA observed each bathroom has a mirror which also serves as a night light. Hot water temperature was measured in the kitchen and all bathrooms and ranged between 106.6*F - 107.7*F. .

(continued on LIC809-C)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOM'S PLACE I	FACILITY NUMBER: 565850346
	VISIT DATE: 05/13/2024

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(continued from LIC809)

The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present; stored in the kitchen and detached garage. An emergency supply of water was also present in the garage. Knives were stored in a locked drawer and cleaning supplies are stored in a locked cabinet under the kitchen sink. Additional cleaning supplies are locked in the closet near the front door entryway. A locked medication cabinet was observed in the dining room. First aid kits were observed in the medication cabinet.

The facility's laundry room is connected to the home but only accessible from outside. Laundry supplies are kept inside the locked closet in the house.

Building and grounds were observed. Patio area contains a shaded seating area for resident use. Outdoor exit gate was observed to be self-closing and self-latching at this time. All passageways were observed to be clear of hazards.

Pre-Licensing is complete and this facility has no deficiencies.

Exit interview conducted and a copy of the report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

LIC809 (FAS) - (06/04)

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