565850348-4-10-2024-29-AS-KDUK-D47RPR-20240410131221

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850348
Report Date: 04/10/2024
Date Signed: 04/10/2024 01:12:32 PM

Document Has Been Signed on 04/10/2024 01:12 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 2		FACILITY NUMBER:	565850348
ADMINISTRATOR:	YUSUF, IBIRONKE		FACILITY TYPE:	740
ADDRESS:	30 LA PATERA CT		TELEPHONE:	(818) 274-1809
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 0	DATE:	04/10/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:12 AM
MET WITH:	Laila Kulungu, Facility Designee		TIME COMPLETED:	01:15 PM

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Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing visit to this property at 10:12AM. 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 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. Applicant completed component II interview on 10/06/2023. During today's visit, Facility Designee completed component III with the LPA.

Beginning at 10:48AM, 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 at 12:11PM 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 common living room, den and dining area are clean and properly furnished. A properly screened fireplace was observed in the living room. A working telephone is present.

The proposed facility has six (6) bedrooms total and a lanai. Four (4) are private resident rooms, one (1) is a shared resident room and one (1) bedroom and the lanai are designated as staff rooms. 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 four (4) bathrooms, one (1) is for shared resident use, one (1) is a private resident restroom, and two (2) are for use by staff and visitors. LPA observed night-lights were present in the hallways. Hot water was measured in the shared restroom and measured higher than the required range. Water temperature was adjusted during the visit and measured just above and at the high end of the appropriate range 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: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOM'S PLACE 2	FACILITY NUMBER: 565850348
	VISIT DATE: 04/10/2024

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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 cabinet under the kitchen sink. A locked medication cabinet was observed in the facility kitchen. First aid kit was observed and was complete. The facility contains a laundry room, containing locked cabinets for chemical storage. A locked garage was observed to contain extra food and storage space, as well as the facility's office.

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.

The following needs to be corrected prior to licensure:

Resident #1 (R1) needs to have their full bed rails removed and replaced with half bed rails.
Hot water temperature needs to consistently measure within the required range.

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: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC809 (FAS) - (06/04)

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