567609849-9-19-2022-29-AS-AASO-CJCQHF-20220917121105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609849
Report Date: 09/17/2022
Date Signed: 09/19/2022 03:38:15 PM

Document Has Been Signed on 09/19/2022 03:38 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 - FERNWOOD		FACILITY NUMBER:	567609849
ADMINISTRATOR:	DANIEL, DADESII		FACILITY TYPE:	735
ADDRESS:	515 FERNWOOD DR		TELEPHONE:	(805) 307-1810
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY: 4		CENSUS: 3	DATE:	09/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Alana Davis		TIME COMPLETED:	12:15 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) Angel Ascencio conducted an unannounced required annual visit to the above facility. LPA Ascencio met with the staff member Alana Davis and explained the reason for the visit. This annual had a specific emphasis on infection control practices and procedures. Administrator Dadesii Daniel was not able to join LPA but authorized staff member Alana Davis to sign documents. At 10:40 a.m., the LPA, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards. BEDROOMS: All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are 4 (four) total bedrooms for resident use – all of which are private rooms. RESTROOMS: There are two (2) bathrooms in the hallway for resident use. One (1) is designated as a staff bathroom. The resident bathrooms has a shower with non-skid materials. The toilet and showers have grab bars.The hot water temperature was tested in the bathrooms and kitchen. Areas were found to be within the range of 105F and 120F. Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2022

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: PCS - FERNWOOD	FACILITY NUMBER: 567609849
	VISIT DATE: 09/17/2022

NARRATIVE

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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. There are 2 of fire extinguishers throughout the house.The facility smoke alarm system is hard wired. The medication room was observed to be locked and contained 30 days of medication. 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 knives are stored in a locked room by the kitchen. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located in a locked room by the kitchen. No flies or other vermin were observed

INFECTION CONTROL: During today’s visit, the LPA spoke with the staff member regarding the facility’s infection control practices at 10:45 AM. There is 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. The 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.

Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2022

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: 09/17/2022

NARRATIVE

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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 does not have 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: 09/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2022

LIC809 (FAS) - (06/04)

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