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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801182
Report Date: 11/30/2022
Date Signed: 11/30/2022 02:14:09 PM

Document Has Been Signed on 11/30/2022 02:14 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:ROSE GARDEN MANOR IIIFACILITY NUMBER:
565801182
ADMINISTRATOR:EMMANUEL SORATORIOFACILITY TYPE:
740
ADDRESS:831 YALE PLACETELEPHONE:
(805) 986-6097
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Amy SoratorioTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required - 1 Year Inspection. This annual had a specific emphasis on infection control practices and procedures. The facility is vendored by Tri-Counties Regional Center as a level 4-E home. The LPA met with staff initially and explained the reason for the inspection. Licensee Amalia Soratorio arrived during the inspection at 10:47 AM.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The carbon monoxide detector and smoke detectors were tested and all functioned properly. The fire extinguisher was last serviced 09/19/2022.

KITCHEN: Knives are stored in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: The LPA observed four private and one shared client room, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: There is one common and one private restroom for client use which were clean and sanitary and in operating condition with hand soap and paper towels. At 10:29 AM the hot water temperature tested at 116.3 degrees F. in the private restroom.

COMMON SPACES: Living room and dining room furniture was observed to be in good condition. The LPA observed the required postings upon entry. The backyard patio is equipped with furniture for clients' use. Medications are stored in a locked cabinet in the hallway closet. Records are stored in a locked cabinet in the living room. Cleaning supplies are stored in a locked cabinet in the garage.

Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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: ROSE GARDEN MANOR III
FACILITY NUMBER: 565801182
VISIT DATE: 11/30/2022
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INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. All facility staff were observed wearing masks. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff are showing symptoms of COVID-19 or test positive for COVID-19.

No deficiencies observed. Exit interview conducted. Report emailed to the Licensee.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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