567609752-2-19-2023-29-AS-SURA-CP7UFU-20230219143319

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609752
Report Date: 02/19/2023
Date Signed: 02/19/2023 02:35:03 PM

Document Has Been Signed on 02/19/2023 02:35 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:	GRANDMA EBING'S SENIOR CARE		FACILITY NUMBER:	567609752
ADMINISTRATOR:	SUDARIO, ELLEN		FACILITY TYPE:	740
ADDRESS:	1110 JANETWOOD DR		TELEPHONE:	(805) 307-1612
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY:	4	CENSUS: 3	DATE:	02/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Cheryl Macht		TIME COMPLETED:	02:30 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) Sandra Urena arrived at the facility unannounced to conduct a required
annual visit at 1:15 p.m. This annual inspection had a specific emphasis on infection control practices and procedures. LPA was greeted by staff and staff contacted Administrator to inform them of the visit. The LPA met with Administrator Cheryl Macht and discussed the reason for the visit.

Infection Control: Upon entry, the facility has a sign in book and sanitizing gel. Infection Control signage was visible at entrance. Temperature was checked, and recorded.

From 1:35 p.m. to 2:15 p.m. LPA Urena and the Administrator conducted a tour inside and outside of the physical plant to ensure there are no health, and safety hazards, and facility is in compliance with Title 22 Regulations.

BEDROOMS: Bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Linens are clean, and in good condition.

BATHROOMS: Bathrooms were clean, shower area was in clean condition with grab bars and a non-skid mat available. Paper towels were available for drying hands. Hand washing signs were displayed, and sufficient amounts of soap, and paper products in each bathroom.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good

condition. At the time of the visit, common seating area and dining room furniture was observed to be in good
condition. Fire extinguisher wa observed to be serviced within the last year.

Continued on LIC 809 – C…

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRANDMA EBING'S SENIOR CARE	FACILITY NUMBER: 567609752
	VISIT DATE: 02/19/2023

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

OUTDOOR SPACE: Backyard has a covered outdoor area equipped with furniture in good repair for residents’ use. There were no bodies of water noted. Side gate is unlocked.

LPA Urena observed an adequate 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’s policies and procedures as it pertains to infection control are adequate

No citations were issued. Exit interview was conducted, the report was reviewed with the Administrator, and a copy of the report was provided. Signatures were obtained.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2