<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802469
Report Date: 05/04/2022
Date Signed: 05/05/2022 08:25:10 AM

Document Has Been Signed on 05/05/2022 08:25 AM - 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:CARMEL HOMEFACILITY NUMBER:
565802469
ADMINISTRATOR:FROILAN MONTESFACILITY TYPE:
740
ADDRESS:1090 CARMEL DRTELEPHONE:
(805) 955-0435
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 4CENSUS: 4DATE:
05/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Monique LopezTIME COMPLETED:
03:28 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 1:58 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Staff Ritah Mutyaba, LVN and explained the reason for the visit. LPA reviewed infection control practices with Program Manager/Administrator Monique Lopez over the phone as she was not in town during LPA's visit. The Administrator authorized Staff to sign this report.

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 and smoke alarms were tested and all functioned properly; they are tested monthly by maintenance staff. The fire extinguishers were last serviced in February of 2022; they are also inspected monthly by maintenance staff.

BEDROOMS: The LPA observed four single-occupancy client bedrooms with exits to the back yard. Rooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: There were three restrooms which were clean and sanitary and in operating condition. COMMON SPACES: The living room and dining room furniture were observed to be in good condition. The LPA observed the required postings in the facility. The backyard patio is equipped with furniture for residents' use. There were two self-latching gates. KITCHEN: Knives and cleaning supplies are stored in a locked cabinet and drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medications are stored in a locked cabinet.

INFECTION CONTROL: 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 and sanitation station. Staff were wearing face masks. There was 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 showing symptoms of COVID or testing positive for COVID.

No deficiencies were observed. Exit interview conducted and a copy of the report emailed to Administrator.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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 1