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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801861
Report Date: 07/24/2024
Date Signed: 07/24/2024 12:21:25 PM

Document Has Been Signed on 07/24/2024 12:21 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ESTRELL HOME CARE LLCFACILITY NUMBER:
425801861
ADMINISTRATOR/
DIRECTOR:		RUBY Q. MARTINEZFACILITY TYPE:
740
ADDRESS:804 LAVONNE DRIVETELEPHONE:
(805) 354-0670
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 3CENSUS: 2DATE:
07/24/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Robert - Designated Back-upTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Rankin arrived at 09:44am to conduct a 1 year annual visit follow-up to the facility above. LPA met Robert Martinez, Caregiver and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Infection Control: The facility Infection Control Plan on file. The facility has a sign in and out clipboard for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Trash cans and waste baskets have tight fitting covers.

Physical Plant & Environment Safety: The facility has 7 bedrooms and 5 bathrooms. The facility is occupying 2 residents. The facility locations designated for residents are clean, safe and sanitary, areas that need additional cleaning and clearing of items were noted to the administrator and caregiver. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. Carbon Monoxide was tested and working properly during visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. Facility was in the process of reorganizing outside area. Facility is well lit inside and outside for safety.

Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ESTRELL HOME CARE LLC
FACILITY NUMBER: 425801861
VISIT DATE: 07/24/2024
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Disinfectant, cleaning solutions and poisons are in locked shed outside and in locked garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with furniture and shade. The facility has telephone and internet service for resident use. The backyard has 5 sheds, sheds that include chemical and/or tools will be locked.

Operational Requirements: The facility has a current plan of operation on file. The Facility is operating in compliance with the granted fire clearance based on the facility sketch. The facility has current liability insurance and expires on 06/23/2025. The facility is approved for a capacity of 3 non-ambulatory and approved for hospice waiver of 2.



Staffing: The facility employes 2 fulltime staff and 1 Administrator, there are also 4 back-up staff and 2 live in adult family members who are not staff, but they are approved on the Guardian list. Staff records are kept confidential. LPA reviewed 4 staff files. Files reviewed had current CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions, and all required documents were present at this visit. Administrator Certificate expires on 04/12/26.

Personnel Records & Training: The facility keeps confidential files. LPA reviewed 3 staff training records for Annual Training Requirements of 20 plus hours. Training records for back-up staff will be completed and provided to LPA.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Two files were reviewed for signed Admission Agreements, Medical Assessments, LIC 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Files reviewed did not have a current Appraisal Needs and Services form for one resident, but that is scheduled to be completed. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The facility does not handle cash resources.
Continued 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ESTRELL HOME CARE LLC
FACILITY NUMBER: 425801861
VISIT DATE: 07/24/2024
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Incidental Medical & Dental: The facility has a medication cabinet in the kitchen that is kept locked. Facility provides or assist in providing transportation to medical and dental appointments when needed. The medications records were reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected medication cabinet for all prescription and PRN medications with Doctors orders. LPA reviewed all residents’ medications, no medications labels were altered, no expired medications, and medications were stored in original containers.

Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects.



Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguisher was charged. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were inaccessible to residents in care in the immediate areas of use. The facility does not have delayed egress. The facility does not currently have residents with oxygen. The facility gate will be updated with self-latching and self-closing equipment, facility was in process of fixing when LPA arrived. The backyard is completely fenced.

Exit interview conducted and copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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