565801541-2-15-2022-29-AS-AASO-CBNRZS-20220215122825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801541
Report Date: 02/14/2022
Date Signed: 02/15/2022 12:33:49 PM

Document Has Been Signed on 02/15/2022 12:33 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:	FINEST LIVING AT CRESTWOOD		FACILITY NUMBER:	565801541
ADMINISTRATOR:	ADELAIDA G. CRUZ		FACILITY TYPE:	740
ADDRESS:	225 CRESTWOOD AVENUE		TELEPHONE:	(805) 212-8303
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY: 6		CENSUS: 5	DATE:	02/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Adelaida Cruz		TIME COMPLETED:	04:10 PM

NARRATIVE

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Licensing Program Analysts (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 2:00 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Adelaida Cruz and discussed the reason for the visit. Entrance interview conducted.

The LPA, along with Administrator, toured the physical plant areas inside and outside at 2:45 p.m. to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 7 total bedrooms – six (6) bedrooms are private for resident use, and one (1) staff room.

RESTROOMS: 3 restrooms were observed to be clean and sanitary and in operating condition. Showers were also observed to have grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA did not observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. Smoke detectors and carbon monoxide was observed to be in operable condition at the time of visit.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage was observed locked and contained the emergency food supply and locked storage cabinet for laundry supplies.

Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022

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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Document Has Been Signed on 02/15/2022 12:33 PM - It Cannot Be Edited

Created By: Angel Ascencio On 02/14/2022 at 03:16 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FINEST LIVING AT CRESTWOOD	FACILITY NUMBER: 565801541
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as 3 out of 3 hand washing stations exceeded normal temperature range, with the highest testing at 137.1 degreee F which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/25/2022
	Plan of Correction
1 2 3 4	Admin stated they will lower the temperature for the hand washing stattions. Admin will take temperature three (3) times a day for three (3) days and send readings to LPA at angel.ascencio@dss.ca.gov.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Kristin Heffernan

LICENSING EVALUATOR NAME:

Angel Ascencio

LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022

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: FINEST LIVING AT CRESTWOOD	FACILITY NUMBER: 565801541
	VISIT DATE: 02/14/2022

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KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Admin stated they are still waiting on the construction company for permit to finish remodeling the kitchen.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices at 3:00 p.m. There is 1 entry into the facility. Upon entry, the facility has a central point for symptom screening. LPA noted that the facility is allowing visitors for both indoor and outdoor visitation. The LPA did not observed an adequate supply of Personal Protective Equipment (PPE). The Admin stated they have PPE at home and will be bringing to facility. They will reach out to case LPA if in need of additional PPE. 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’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:

- Post PINs and educate staff, residents, and families on changing policies and procedures from the Department
- Required COVID - 19 poster, cough etiquette poster, etc.
- PPE

LPA inspected water temperature for kitchen, and two (2) restroom. Water temperature exceeded range of 120 degrees F. Admin stated they will lower temperature.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of

Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in

civil penalties.

One (1) citations was issued during today’s visit. Exit interview conducted. A copy of the report and appeal rights was provided via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022

LIC809 (FAS) - (06/04)

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