565802133-7-29-2023-29-AS-KDUK-CU7RGR-20230729130110

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802133
Report Date: 07/29/2023
Date Signed: 07/29/2023 01:01:18 PM

Document Has Been Signed on 07/29/2023 01:01 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 IV		FACILITY NUMBER:	565802133
ADMINISTRATOR:	SORATORIO, AMALIA		FACILITY TYPE:	740
ADDRESS:	745 BERKSHIRE PLACE		TELEPHONE:	(805) 246-5148
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 6		CENSUS: 6	DATE:	07/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Amalia Soratorio		TIME COMPLETED:	01:10 PM

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:33AM. LPA initially met with Facility Designee Marilyn Galang. Licensee Amalia Soratorio was contacted via telephone and arrived at the facility at 10:20AM. Entrance interview conducted.

Beginning at 09:58AM, the LPA, along with facility staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Hardwired smoke and Carbon Monoxide detectors were tested at 12:10PM and were functional at the time of the visit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 4 (four) total bedrooms; 2 (two) are designated for private resident use and 2 (two) are designated as shared resident rooms.

RESTROOMS: The LPA observed 2 (two) restrooms in the facility; one is a shared restroom and one is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in the private resident restroom at 12:29PM and measured at 109.8 degrees Fahrenheit, which is within the required range.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be adequately inaccessible. Laundry room was observed with locked chemical storage. Fire extinguishers were observed to be fully charged and last serviced on 09/19/2022.

Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2023

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 IV	FACILITY NUMBER: 565802133
	VISIT DATE: 07/29/2023

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OUTDOOR SPACE: The backyard has an enclosed patio and outdoor area equipped for resident use. There were no bodies of water noted. The detached garage was observed locked and contained storage.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, as well as emergency food and water supply. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

RECORD REVIEW: Resident record review began at 10:11AM and staff files were reviewed at 11:38AM. Records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, personal rights, and resident cash resources. 5 (five) resident records reviewed were complete and contained all required documents. 5 (five) staff files were reviewed; 2 (two) of 5 (five) care staff files reviewed contained proof of CPR training, but training certificates did not indicate first aid training was completed.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit at 11:30AM, the LPA reviewed the facility’s infection control practices and emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency Disaster Plan was observed to be completed and reviewed annually. Emergency drills are conducted monthly, with the last documented drill on 07/01/2023.

MEDICATION REVIEW: Medications were observed locked in the hallway cabinet. Review began at 11:53AM. Medications for 5 (five) residents were observed. All 5 (five) of 5 (five) residents' medications were observed to be maintained and administered in compliance with regulation.

INTERVIEWS: Throughout today's visit, LPA interviewed 3 (three) residents and 2 (two) staff.

No citations issued. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2023

LIC809 (FAS) - (06/04)

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