567609825-11-1-2023-29-AS-KDUK-CX6UET-20231101153141

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609825
Report Date: 11/01/2023
Date Signed: 11/01/2023 03:31:47 PM

Document Has Been Signed on 11/01/2023 03:31 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:	ESTATE HOME 2, THE		FACILITY NUMBER:	567609825
ADMINISTRATOR:	ALARCON, ESTRELLA		FACILITY TYPE:	740
ADDRESS:	703 CAMINO CONCORDIA		TELEPHONE:	(805) 358-3260
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	3	CENSUS: 3	DATE:	11/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:28 AM
MET WITH:	Estrella (Lillian) Alarcon		TIME COMPLETED:	03:35 PM

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 10:28AM. LPA met with Licensee/Administrator Estrella (Lillian) Alarcon. Entrance interview conducted.

Beginning at 10:53AM, the LPA, along with Licensee 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:

Hardwired combination smoke and carbon monoxide detectors were tested at 02:34PM and were functional at the time of the visit. Fire extinguishers were observed to be fully charged and purchased on 07/17/2023.

OUTDOOR SPACE: The backyard is shared between this facility and another related facility. The shared yard has a covered outdoor area equipped with furniture for resident use. The facility does have a fountain, but it was observed to be empty 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. Emergency food and water supply are stored in the garage of another facility sharing the same outdoor property. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

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.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

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: ESTATE HOME 2, THE	FACILITY NUMBER: 567609825
	VISIT DATE: 11/01/2023

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BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 2 (two) total bedrooms; one is a shared bedroom and the other is a private bedroom.

RESTROOMS: The LPA observed 2 (two) restrooms in the facility, both of which are designated for resident use. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in shared resident restroom and measured within the required range.

RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 1 (one) resident record reviewed was complete and contained all required documents. 4 (four) staff files reviewed were complete and contained all required documents.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually, as required. Emergency drills are conducted monthly, with the last drill documented on 10/06/2023.

INTERVIEWS: Throughout the visit, LPA interviewed 2 (two) staff and 1 (one) resident.

MEDICATION REVIEW: Medications for 1 (one) resident was observed. Medications reviewed were observed to be maintained and administered in compliance with regulation.

During today's visit, LPA gathered the following items:

LIC 500
A copy of the facility's liability insurance

No deficiencies cited. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC809 (FAS) - (06/04)

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