567609701-4-12-2024-29-AS-TCAA-D49KYZ-20240412081956

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609701
Report Date: 04/10/2024
Date Signed: 04/12/2024 08:20:58 AM

Document Has Been Signed on 04/12/2024 08:20 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ASSISTED LIVING BY RAPHAEL		FACILITY NUMBER:	567609701
ADMINISTRATOR:	NAPOLITANO, RALPH		FACILITY TYPE:	740
ADDRESS:	91 CALETA DR		TELEPHONE:	(805) 389-8192
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY:	4	CENSUS: 0	DATE:	04/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:17 PM
MET WITH:	Eric Schott		TIME COMPLETED:	04:15 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 02:17 p.m. The administrator/licensee was not available at the time of the visit. LPA met with caregiver Eric Schott and explained the reason for the visit. The administrator had put all of the paperwork together in anticipation for this annual visit. This facility has no residents at this time.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area.

The side yard has a covered outdoor area equipped with furniture for resident use. Gates were observed to be self-closing and self-latching.

The fire extinguisher appeared fully charged and purchased on 03/2/2024. Combination hardwired smoke detectors/carbon monoxide detectors were tested and functioned properly at the time of the visit.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives were observed to be locked in a kitchen drawer.

BEDROOMS: The facility consists of four (4) bedrooms, of which two (2) are designated for resident use and two (2) are for staff use. LPA observed the two (2) shared resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
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)

Page: 1 of 2

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: ASSISTED LIVING BY RAPHAEL	FACILITY NUMBER: 567609701
	VISIT DATE: 04/10/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC 809

RESTROOMS: The LPA observed 3 restrooms in the facility; one is a common shared restroom and 2 (two) are for staff use. The resident restroom is clean and sanitary and in operating condition with grab bars and non-skid surfaces. The water temperature was tested in the resident restroom at 115 degrees Fahrenheit.

INFECTION CONTROL: LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

RECORDS & INTERVIEWS: There were no residents at the facility. There is only one staff at the facility for which records were complete. LPA interviewed the staff who was able to answer the questions appropriately.

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

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
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)

Page: 2 of 2