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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850358
Report Date: 06/12/2024
Date Signed: 06/12/2024 04:38:21 PM

Document Has Been Signed on 06/12/2024 04:38 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:ROSE GARDEN MANORFACILITY NUMBER:
565850358
ADMINISTRATOR/
DIRECTOR:		SORATORIO, AMALIAFACILITY TYPE:
735
ADDRESS:1731 S. VENTURA ROADTELEPHONE:
(805) 890-0607
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Amalia SoratorioTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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At 12:40 p.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. When the LPA arrived, there were no clients and staff present. At 12:51 Care staff Adelou Cantada arrived and was explained the reason for the visit. Shortly thereafter, administrator Amalia Soratorio arrived.

At 12:55 p.m., the LPA conducted a tour of the physical plant with Staff Adelou 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 five (5) client bedrooms, and two (2) bathrooms. The home is vendored by Tri-Counties Regional Center as a level 3 home. The LPA observed two fire extinguishers at the facility, which were fully charged and last serviced 10/16/2023. At 01:01 p.m., all smoke alarms and carbon monoxide detectors were tested. LPA observed all required postings throughout the facility.

Kitchen: 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 are stored in a locked drawer and cleaning supplies are stored in a locked cabinet under the sink. Food is prepared based on the menu. Snacks and beverages are always available for residents. At 12:57 p.m. the LPA observed a locked cabinet where cereal, mac and cheese, crackers, juices, and other food items were stored. Upon observation, administrator indicated that they never lock food, that the locked cabinet used to be where they stored the medication, they now store food inside, and staff must of gotten confused and locked the cabinet. Cabinet was unlocked and remained unlocked during today’s visit. Additional food was observed in unlocked cabinets in the kitchen.

Bedrooms: The LPA observed all resident bedrooms properly furnished 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: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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: ROSE GARDEN MANOR
FACILITY NUMBER: 565850358
VISIT DATE: 06/12/2024
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Bathrooms: The LPA observed the private Jack and Jill residents’ bathroom and the outside bathroom to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene. At 01:52 p.m., water temperature in the outside restroom was measured at 112.3 degrees Fahrenheit. At 4:03 p.m., water temperature in the Jack and Jill bathroom was measured at 113.3 degrees Fahrenheit.

Common Areas: These included the living, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature of 72 degrees. There was a fireplace in the living room which was properly screened. There were no obstructions and/or tripping hazards throughout the facility.



The garage: The LPA observed the garage, where the emergency water is stored, and the washer and dryer are held. The garage is used to store additional supplies. The garage is unlocked.

Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water on the premises.

Interviews: During the visit the LPA conducted two (2) client and two (2) staff interviews. No immediate concerns voiced at this time.

Record Review: At 1:41 p.m., a review of facility files was initiated. Facility records are stored in a locked cabinet in the office. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 04/30/2024). The LPA obtained Client Roster, and Staff Roster. The LPA reviewed five (5) out of six (6) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. The LPA reviewed five (5) out of seven (7) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. All client and staff documents reviewed appeared complete and current.

Medications: Medications review began at 03:18 p.m.; medications are centrally stored and locked in a cabinet in the office, medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.



Exit interview conducted. Report provided to Administrator.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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