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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609799
Report Date: 04/15/2022
Date Signed: 04/15/2022 04:11:14 PM

Document Has Been Signed on 04/15/2022 04:11 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:CONNIE'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
567609799
ADMINISTRATOR:CORTES, CONSUELO AFACILITY TYPE:
735
ADDRESS:614 E NECTARINE STTELEPHONE:
(805) 240-2188
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 5DATE:
04/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Nicole CortesTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) KaSandra Lopez an unannounced Required -1 Year inspection. The LPA arrived at 11:23 AM and met with staff Nicole Cortes and explained the reason for today's inspection. The home is vendored by Tri-Counties Regional Center as a level 2 home. At 11:25 AM, the LPA spoke with Licensee Floro Cortes on the telephone and advised that he still needs to submit an updated LIC 200 and new administrator information for this home due to the passing of the other Partner/Licensee. The Licensee agreed to submit this information as soon as possible.

The LPA, along with the staff, 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. This Required - 1 Year inspection has a specific emphasis on infection control practices and procedures.

Kitchen The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Cleaning supplies and medications are stored in locked cabinets.

Common Areas: The living room was furnished appropriately. The two fire extinguishers were fully charged and last serviced on 09/30/2021. Infection control signs are posted through out the facility. The facility has one common and one private restroom for resident use. Restrooms were observed to be clean and sanitary with hand soap and napkins. At 11:43 AM the hot water temperature was tested in the common hallway restroom and it measured at 109.4 degrees F. The backyard has seating for resident use. The carbon monoxide detector and smoke alarms in the common areas and bedrooms were tested at 11:53 AM and were found to be operational.

Bedrooms: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2022
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: CONNIE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 567609799
VISIT DATE: 04/15/2022
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Infection Control: During today’s visit, the LPA spoke with staff regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. Infection control signs are posted in the restrooms and through out the facility. The LPA observed an adequate supply of Personal Protective Equipment (PPE). The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were cited during today's inspection. Exit interview and report reviewed with staff. A copy of the report will be emailed to the Licensee.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC809 (FAS) - (06/04)
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