567609650-7-29-2023-29-AS-KDUK-CU7TZG-20230729151020

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609650
Report Date: 07/29/2023
Date Signed: 07/29/2023 03:10:26 PM

Document Has Been Signed on 07/29/2023 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:	CLARKS RESIDENTIAL CARE HOME LLC		FACILITY NUMBER:	567609650
ADMINISTRATOR:	CARINO II, RICHARD T		FACILITY TYPE:	735
ADDRESS:	4525 READING DR		TELEPHONE:	(805) 246-8446
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 4		CENSUS: 4	DATE:	07/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:12 PM
MET WITH:	Casey Carino, Christian "Ryan" Carino, and Charles "Martin" Carino		TIME COMPLETED:	03:15 PM

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 01:12PM. The LPA initially met with facility staff. The Facility Designees were contacted via telephone and arrived beginning at 01:35PM. LPA explained the reason for today's visit. Entrance interview conducted.

The facility is vendored through Tri-Counties Regional Center as a level 4 home.

Beginning at 01:38PM, the LPA, along with Facility Designees, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was observed:

The hardwired carbon monoxide and smoke alarms were tested at 02:37PM and all functioned properly. The fire extinguisher was observed to be fully charged and last serviced on 12/19/2022.

BEDROOMS: The LPA observed four single-occupancy client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: Restrooms are clean and sanitary and in operating condition. Hot water was checked in the private resident restroom and measured at 111.6 degrees Fahrenheit. LPA attempted to measure the hot water in the common resident restroom, however the sink drained very slowly and water level rose, so LPA discontinued checking the water temperature.

KITCHEN: Knives and cleaning supplies are stored in locked cabinets. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

COMMON SPACES: Living room, tv room, and dining room furniture was observed to be in good condition. The LPA observed the required postings upon entry. The backyard patio contains a shaded area and is

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2023

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: CLARKS RESIDENTIAL CARE HOME LLC	FACILITY NUMBER: 567609650
	VISIT DATE: 07/29/2023

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equipped with furniture for clients' use. Garage was observed to be utilized as an activity space for clients and also contained laundry area, locked chemical storage as well as extra food and emergency supply.

CLIENT FILES/CASH RESOURCES: Beginning at 01:58PM, LPA reviewed all 4 (four) client files for, but not limited to: physician's report, proof of TB test, Admission Agreement, and cash resources. All 4 (four) of 4 (four) client files reviewed were complete and contained all documentation required.

MEDICATION REVIEW: Beginning at 02:20PM, LPA reviewed medications for all 4 (four) clients. All medications reviewed were documented and stored in compliance with regulation.

STAFF FILES: Not reviewed during today's visit.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: Not reviewed during today's visit.

INTERVIEWS: During today's visit, LPA interviewed 1 (one) client. Additional client and staff interviews will be completed during the annual continuation visit.

Due to time constraints, LPA will return at a later date to continue the inspection.

No citations issued. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2023

LIC809 (FAS) - (06/04)

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