197609562-3-29-2022-29-AS-MGCZ-CCYRAQ-20220329125133

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609562
Report Date: 03/29/2022
Date Signed: 03/29/2022 12:52:18 PM

Document Has Been Signed on 03/29/2022 12:52 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:	APPLEGATE @ SIRIUS		FACILITY NUMBER:	197609562
ADMINISTRATOR:	CARMONA, IRMA		FACILITY TYPE:	740
ADDRESS:	2614 SIRIUS STREET		TELEPHONE:	(805) 380-9400
CITY:	THOUSANDS OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 6		CENSUS: 6	DATE:	03/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Irma Carmona		TIME COMPLETED:	12:50 PM

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Licensing Program Analyst (LPA), Martha Guzman Chavez conducted an unannounced visit to Applegate @ Sirius to conduct a Required 1-Year Annual Inspection at 10:15 a.m. The last annual conducted at this facility was on 4/03/2019. This annual has a specific emphasis on infection control practices and procedures. The LPA was greeted and scanned at the door by staff, Emma Carmona. The Administrator, Irma Carmona arrived shortly after and was explained the reason for the visit. Entrance interview.

At 10:50 a.m., the LPA began the physical plant tour with the Administrator of the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA observed the kitchen/dining area to be clean and kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The LPA observed the kitchen refrigerator and pantry to be fully stocked at the time of visit. Knives and sharps are locked in a drawer inaccessible to residents.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. The LPA observed six (6) bathrooms for resident use. Each bedroom has their own private bathroom. The hot water temperature was measured and in compliance at the time of visit between 105.8- and 109.4-degrees Fahrenheit.

...Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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: APPLEGATE @ SIRIUS	FACILITY NUMBER: 197609562
	VISIT DATE: 03/29/2022

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…Continued from LIC 809...

COMMON SPACES: The LPA observed the living room area which is clean and properly furnished with seating, a table, and television for resident use. The LPA observed one resident in the living room watching television during time of visit. The LPA observed two fire extinguishers fully charged on 3/01/2022. Medications and First-Aid Kit were also observed in a locked closet adjacent to the dining room.

GARAGE AND GROUNDS: The garage is locked and attached to the house. There is one (1) additional refrigerator and freezer in the garage with perishable items in good condition. The LPA observed a covered patio area with patio furniture including a table and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. No large bodies of water accessible to residents at the time of visit.

During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, symptoms of COVID-19, and CDSS PINS. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE). Staff were observed wearing face coverings. All staff are fully vaccinated. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation.

Exit interview conducted. No citations issued. A copy of the report will be provided to the Administrator via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC809 (FAS) - (06/04)

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