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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801861
Report Date: 04/21/2022
Date Signed: 04/21/2022 12:04:24 PM

Document Has Been Signed on 04/21/2022 12:04 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:ESTRELL HOME CARE LLCFACILITY NUMBER:
425801861
ADMINISTRATOR:RUBY Q. MARTINEZFACILITY TYPE:
740
ADDRESS:804 LAVONNE DRIVETELEPHONE:
(805) 354-0670
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 3CENSUS: 1DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Estrellita MartinezTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Toan Luong conducted an unannounced Annual One Year Infection Control visit. LPA met with Caregiver/Staff (S1) Estrellita Martinez and explained the purpose of the visit. LPA toured the facility.

At 11:00 a.m., LPA discussed items in the Infection Control Module with S1 and noted that handwashing sign was not posted in a staff bathroom but was posted in all other resident bathrooms. One staff live-in room did not have beds 6 feet apart or 3 feet apart with head to toe orientation, but the room was occupied by one person. The facility does not have any staff fit tested with N95 mask. The facility did not have an adequate supply of PPE as interview with S1 reveals that the facility does not have N95 masks on hand and a limited of supply of gowns. LPA reviewed all items in the infection control module with S1 to satisfaction.

LPA conducted exit interview and emailed report and appeal rights to the facility.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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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