567609979-6-28-2021-29-AS-EPEI-C4ER2V-20210628123858

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609979
Report Date: 06/28/2021
Date Signed: 06/28/2021 12:40:11 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) 246-5831
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 5	DATE:	06/28/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	TERESA P 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 Analysts (LPAs) Emily Peraldi, and Martha Guzman Chavez arrived at the facility unannounced to conduct a required annual visit at 10:15am. LPAs were greeted and screened by Administrator, TERESA SACOLLES. This annual had a specific emphasis on infection control practices and procedures. Between 10:18 am and 10:45 am, LPAs began the physical plant tour inside and outside to ensure there are no health and safety hazards and facility is in compliance with the Title 22 Regulations. OUTDOOR SPACE: The LPAs observed the backyard, which has a covered outdoor area for resident use. There is a self-latch gate on the side of the facility. KITCHEN: The LPAs observed the knives to be stored in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Emergency food and water located in the locked garage. At 10:20 am, LPAs observed staff preparing food in the kitchen. BEDROOMS: LPAs observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Passageways were free and clear from obstruction. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are clean and sanitary and in operating condition. Restrooms had non-slip shower mats and grab bars. LPA tested water temperature and it measured at 106.2 F. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

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: RON AND TESS HOME CARE LLC	FACILITY NUMBER: 567609979
	VISIT DATE: 06/28/2021

NARRATIVE

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Continued from LIC 809

Common Areas: LPAs observed common areas to be clean and properly furnished. LPAs observed the fire extinguisher charged and last serviced on 01/22/2021. Medication and first aid kit kept in a locked cabinet located in the living area. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the garage.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.
The LPAs observed an adequate supply of Personal Protection 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; however, the facility’s policies and procedures as it pertains to infection control are adequate.
The following recommendations were made:

- Posting Provider Information Notices (PINs) and educating staff, residents, and families on changing policies and procedures from the Department.

Between 11:15 am - 12:00 pm LPAs conducted Infection Control mitigation module with Administrator.

Exit interview conducted. Report issued and a copy of the report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC809 (FAS) - (06/04)

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