565850347-11-28-2023-29-AS-KDUK-CXZV79-20231128151046

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850347
Report Date: 11/28/2023
Date Signed: 11/28/2023 03:10:50 PM

Document Has Been Signed on 11/28/2023 03:10 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:	MOM'S PLACE 3		FACILITY NUMBER:	565850347
ADMINISTRATOR:	IBIRONKE, YUSUF		FACILITY TYPE:	740
ADDRESS:	975 VALLEY VISTA DRIVE		TELEPHONE:	(818) 274-1809
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 0	DATE:	11/28/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Joseph Jose & Yusuf Ibironke		TIME COMPLETED:	03:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing visit to this property at 10:10AM. LPA met with applicant representative Joseph Jose and Administrator Yousuf Ibironke. This application is for a Change of Ownership Application (CHOW) and the current licensed facility has residents in care. The applicant has obtained fire clearance for four (4) bedridden, one (1) ambulatory, and one (1) non-ambulatory with a total capacity of six (6) residents. The proposed facility has a pending Dementia care plan and a pending hospice care waiver for six (6) residents. Applicant completed component II interview on 10/03/2023. During today's visit, Administrator completed component III with the LPA.

Beginning at 10:39AM, 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 at this time. Sprinkler system was tested during the fire inspection and functioned properly. Fire extinguisher was observed to be fully charged and purchased on 11/16/2023. Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The two (2) common living and dining areas are clean and properly furnished. Properly screened fireplaces were observed in each of the living rooms. A working telephone is present.

The proposed facility has six (6) bedrooms total, of which four (4) are private rooms, one (1) is a shared resident room and one (1) is designated as a staff room. 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. The proposed facility has three (3) bathrooms, two (2) are for shared resident use and one (1) is a private resident restroom. LPA observed night-lights were present in the hallways. While hot water in one (1) shared restroom and in the kitchen initially measured high, water temperature was adjusted during the visit and measured within the appropriate range in all common sinks prior to the end of today's visit.

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: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

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: MOM'S PLACE 3	FACILITY NUMBER: 565850347
	VISIT DATE: 11/28/2023

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The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present, as well as, a seven-day supply of emergency water. Knives were stored in a locked drawer and cleaning supplies are stored in a locked entryway closet. The facility contains a laundry area, containing locked cabinets for chemical storage. A locked medication cabinet was observed, as well as a locked cabinet designated for record storage. First aid kit was observed and was complete.

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

This report will be sent to the Centralized Application Bureau (CAB). 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.

Exit interview conducted and 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: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

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