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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850406
Report Date: 08/29/2024
Date Signed: 08/29/2024 10:18:26 AM


Document Has Been Signed on 08/29/2024 10:18 AM - 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:SALLY RESIDENTIAL CARE HOME 3FACILITY NUMBER:
565850406
ADMINISTRATOR:AKINMADE, OLUWATOSINFACILITY TYPE:
740
ADDRESS:953 ANADANTE COURTTELEPHONE:
(818) 274-1809
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:6CENSUS: 6DATE:
08/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Sara JacksonTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Martha Arroyo conducted a Subsequent Pre-Licensing Visit to the facility today. The reason for this visit is to update the fire clearance approved after the pre-licensing visit initiated on 08/06/2024. LPA met with Applicant Representative, Sara Jackson as this is a change of ownership application from Sally’s Residential Care Home, Inc. #565800706 to Sally Residential Care Home 3 #565850406. The applicant has obtained fire clearance for a total capacity of six (6) residents, all of which may be bedridden in bedrooms #1 - #4 and bedroom #5 approved for ambulatory only. The facility has a dementia program in place.

During today’s visit, the LPA toured the physical plant areas to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations and conducted a medication review. The following was observed:

The LPA observed two (2) resident restrooms, which were clean and sanitary and in operating condition with non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The LPA observed five (5) resident bedrooms; four (4) bedrooms are designated as single occupancy; and one (1) bedroom is designated as double occupancy. All resident bedrooms were observed to be furnished appropriately and had sufficient lighting. Fire clearance also approved for staff bedroom on premises. The LPA inspected the kitchen/food service area. The facility has a sufficient supply of perishable and non-perishable food. All indoor and outdoor passageways were free from obstructions in case of an emergency. No bodies of water noted at the time of the visit.

Report Continued on LIC 809C...
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
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: SALLY RESIDENTIAL CARE HOME 3
FACILITY NUMBER: 565850406
VISIT DATE: 08/29/2024
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Report Continued from LIC 809...

Physical plant is consistent with the updated facility sketch/floor plan and fire clearance approved from 08/14/2024. The physical plant of this facility location is in compliance with Title 22 regulations at this time.

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. The report was reviewed, and a copy was provided.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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