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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802427
Report Date: 06/20/2022
Date Signed: 06/20/2022 02:13:40 PM

Document Has Been Signed on 06/20/2022 02:13 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:DELPHINIUM MANORFACILITY NUMBER:
565802427
ADMINISTRATOR:GONZALES, HERMIFACILITY TYPE:
740
ADDRESS:691 DELPHINIUM PLTELEPHONE:
(805) 919-9770
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: 6CENSUS: 6DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Hermi Gonzales, Administrator TIME COMPLETED:
02:15 PM
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 Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 12:56 p.m., the LPA was greeted and screened by staff. At 1:12 p.m., the Administrator, Hermi Gonzales arrived at the facility. This annual had a specific emphasis on infection control practices and procedures.

At 1:12 p.m., the LPA, along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:11 p.m., hot water measured at 110.8 degree Fahrenheit. Medications and first aid kits are located in a locked living room cabinet near the kitchen area.

COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 11/30/2021. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. All exits have functioning auditory devices. At 1:34 p.m., fire alarms and carbon monoxide detectors were tested and functioning properly.

BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level.

RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 1:32 p.m., hot water measured at 107.1 degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
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: DELPHINIUM MANOR
FACILITY NUMBER: 565802427
VISIT DATE: 06/20/2022
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OUTDOOR SPACE: At 1:29 p.m., the LPA observed the back patio which has a covered outdoor area for resident use. There is a self-latching gate designated for an emergency exit.

GARAGE: The garage is attached to the house and remains locked and inaccessible to residents. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the garage. The laundry units are located inside the garage.

INFECTION CONTROL: At 1:13 p.m., the LPA conducted Infection Control mitigation module with the Administrator. During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. The LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. 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 has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.


No deficiencies were observed at this time. Exit interview conducted with the Administrator. Report issued and a copy of the report will be provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC809 (FAS) - (06/04)
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