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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609849
Report Date: 08/17/2021
Date Signed: 08/19/2021 02:15:59 PM

Document Has Been Signed on 08/19/2021 02:15 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:PCS - FERNWOODFACILITY NUMBER:
567609849
ADMINISTRATOR:DANIEL, DADESIIFACILITY TYPE:
735
ADDRESS:515 FERNWOOD DRTELEPHONE:
(805) 307-1810
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 4CENSUS: 4DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Dadesii DanielTIME COMPLETED:
12:15 PM
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Licensing Program Analysts (LPAs) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 10:37 AM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Dadesii Daniel and discussed the reason for the visit. Entrance interview conducted.

The LPA, along with the Administrator, toured the physical plant areas inside and outside at 11:10 AM to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 4 (four) total bedrooms for resident use – all of which are private rooms.

RESTROOMS: Public restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters.

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. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. The medication room was observed to be locked and contained 30 days of medication.

Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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: PCS - FERNWOOD
FACILITY NUMBER: 567609849
VISIT DATE: 08/17/2021
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The garage was observed locked and contained the emergency food supply, and a laundry area that contained laundry supplies. The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices at 11:25 AM. There is 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. LPA noted that the facility is allowing visitors for both indoor and outdoor visitation. The 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 has not had a confirmed case of COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate.


No citations were issued during today’s visit. Exit interview conducted. A copy of the report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC809 (FAS) - (06/04)
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