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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850358
Report Date: 05/31/2023
Date Signed: 05/31/2023 03:31:03 PM

Document Has Been Signed on 05/31/2023 03:31 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:ROSE GARDEN MANORFACILITY NUMBER:
565850358
ADMINISTRATOR:SORATORIO, AMALIAFACILITY TYPE:
735
ADDRESS:1731 S. VENTURA ROADTELEPHONE:
(805) 890-0607
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 0DATE:
05/31/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Amalia SoratorioTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Amalia Soratorio. This is a relocation application of which facility Rose Garden Manor 565800349 is relocating this location. The facility is vendored by Tri-Counties Regional Center and as a level three home. Component III was conducted during the inspection.

At 1:04 PM, a physical plant tour was conducted inside and out. The home is single story. The physical plant is consistent with the submitted facility sketch/floor plan. An approved fire clearance was granted for six ambulatory residents. The facility has four private resident bedrooms and one shared bedroom. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture. There is no staff room therefore, the facility will have awake night staff only. All rooms were free of odors. All window screens were clean and maintained in good repair.

There is one common restroom in the hallway and a shared restroom between bedrooms 3 and 4. The resident restrooms have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the shared restroom was found to be within the range of 105*F and 120*F.

Resident and staff records will be stored in a locked cabinet. Medications will be centrally stored in a locked cabinet in the kitchen. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. Kitchen knives are stored in a locked drawer in the kitchen. There is supply of dishes, utensils, pots, pans and drink ware. The supply of nonperishable food is adequate. There are no pesticides 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 garage. Report continued LIC 809-C.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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: ROSE GARDEN MANOR
FACILITY NUMBER: 565850358
VISIT DATE: 05/31/2023
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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. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non-private bathrooms. There is a screened fireplace in the living room. 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.
The facility smoke alarm system is hard wired. The smoke detectors and carbon monoxide detectors were tested at 1:08 PM and functioned properly during the time of visit. There are three fire extinguishers throughout the house. They are fully charged and do not exceed the expiration date of 09/19/2022.
The laundry area is located in the garage. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in garage. The applicant will transfer the phone line from the currently licensed home to this home once the licensed is approved. The emergency exiting plans/sketch are posted, along with other required postings.

The exterior passageways were clean and clear of any obstructions. The front yard is enclosed and gated with covered seating for resident use. The backyard also has additional seating for resident use. The entire property is fenced. The sides of the house are separated from the front yard by gates There no bodies of water on the premises at the present time. The garage is accessible from the house. Any items that could pose a danger will be secured in locked cabinets.

Pre-Licensing is complete and this facility has no corrections to be submitted.

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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
LIC809 (FAS) - (06/04)
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