567609979-7-15-2020-29-AS-KLOZ-BRJT3P-20200715142241

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609979
Report Date: 07/15/2020
Date Signed: 07/15/2020 02:23:34 PM

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:	RON AND TESS HOME CARE LLC		FACILITY NUMBER:	567609979
ADMINISTRATOR:	SACOLLES, TERESA P.		FACILITY TYPE:	740
ADDRESS:	4810 JUSTIN WAY		TELEPHONE:	(805) 302-0236
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 0	DATE:	07/15/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Teresa Sacolles		TIME COMPLETED:	12:45 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) KaSandra Lopez conducted an announced Pre-licensing inspection with Administrator/Licensee Representative Teresa Sacolles. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s inspection was conducted via video call with Ms. Sacolles. Component III was completed by the licensee representative on 02/11/2020 in the Woodland Hills Regional Office. The facility is currently licensed as Amity & Joy Home Care 565801905 which has four residents in care. The LPA conducted a physical plant tour with the administrator to ensure there are no health and safety hazards and the facility is in compliance. The facility is fire cleared for six non-ambulatory residents of which one resident may be bedridden. KITCHEN/FOOD SERVICE AREA: The facility had a sufficient supply of non-perishable foods. Knives and sharp items will be stored in a locked drawer. Cleaning supplies and disinfectants will be stored underneath the locked kitchen sink and in locked cabinets in the garage. The facility has a sufficient supply of plates, cups and utensils. COMMON AREAS: The living room area and dinning areas are furnished appropriately for six residents. Paint, windows, window coverings, and floors appeared to be in good repair. The LPA observed the required postings. The facility has a working land line phone. The smoke alarms and carbon monoxide detector were tested at 12:09 PM and were operational. The fire extinguisher was fully charged and last serviced on 01/22/2020. Medications and facility records will be stored in locked cabinets. First aid supplies were checked and complete. Facility has activities for resident use. Resident bedrooms had required furnishings and facility had a sufficient supply of linens and hygiene products. Report continued on LIC 809-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2020

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: RON AND TESS HOME CARE LLC	FACILITY NUMBER: 567609979
	VISIT DATE: 07/15/2020

NARRATIVE

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The two resident bathrooms were observed to be sanitary and in good repair. Both bathrooms had grab bars and non-skid mats in the showers. At 12:19 PM the hot water temperature in the common hallway bathroom was tested by the administrator and measured at 110 degrees F. Laundry services and locked storage for cleaning supplies were observed in the garage. The facility had sufficient emergency lighting.
The back yard area is enclosed. Currently there is not sufficient outdoor seating for six residents and one side gate is not self latching.

The following needs to be completed/proof submitted prior to the facility being licensed:

Proof of sufficient outdoor seating for six residents

Proof the side gate is self-latching.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted and report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2020

LIC809 (FAS) - (06/04)

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