567609722-6-30-2022-29-AS-EPEI-CFVTHT-20220630144518

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609722
Report Date: 06/30/2022
Date Signed: 06/30/2022 02:45:59 PM

Document Has Been Signed on 06/30/2022 02:45 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:	GRANNYS HOME		FACILITY NUMBER:	567609722
ADMINISTRATOR:	HERNANDEZ, VICTOR		FACILITY TYPE:	740
ADDRESS:	1831 BERNADETTE ST		TELEPHONE:	(805) 278-2273
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY:	6	CENSUS: 6	DATE:	06/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:38 PM
MET WITH:	Victor Hernandez, Licensee		TIME COMPLETED:	02:50 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) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 1:38 p.m., the LPA was greeted and screened by the Licensee, Victor Hernandez. This annual had a specific emphasis on infection control practices and procedures. At 1:55 p.m., the LPA, along with Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. The sinks had sufficient liquid soap, and paper towels. At 1:58 p.m., hot water measured at 105.4-degree Fahrenheit. COMMON AREAS: The LPA observed common areas to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 04/24/2022. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 2:05 p.m., fire alarms and carbon monoxide detectors were tested and functioned properly. Medications and first aid kits are located in a locked medication room/closet near the entrance. Night lights were observed in the hallway. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 2:08 p.m., hot water measured at 110.4-degree Fahrenheit. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

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: GRANNYS HOME	FACILITY NUMBER: 567609722
	VISIT DATE: 06/30/2022

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OUTDOOR SPACE: At 2:03 p.m., the LPA observed the back patio which has a covered outdoor area for resident use. There are two (2) self-latching gates designated for an emergency exits.

GARAGE: The garage is attached to the house and remains locked and inaccessible to residents. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the garage. The laundry units are located inside the garage.

INFECTION CONTROL: At 1:45 p.m., the LPA conducted Infection Control mitigation module with the Licensee. During today’s visit, the LPA spoke with the Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. The LPA observed a 30-day supply of Personal Protection 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 has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were observed at this time. Exit interview conducted with the Licensee. Report issued and a copy of the report will be provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

LIC809 (FAS) - (06/04)

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