565802469-6-3-2024-29-AS-MARO-D5VTDZ-20240603143909

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802469
Report Date: 06/03/2024
Date Signed: 06/03/2024 02:39:53 PM

Document Has Been Signed on 06/03/2024 02:39 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:	CARMEL HOME		FACILITY NUMBER:	565802469
ADMINISTRATOR/ DIRECTOR:	FROILAN MONTES		FACILITY TYPE:	740
ADDRESS:	1090 CARMEL DR		TELEPHONE:	(805) 955-0435
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 4		CENSUS: 4	DATE:	06/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Cristina Williams		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today. The last annual conducted at this facility was on 06/05/2023. When the LPA arrived, there were three (3) staff and three (3) residents present. The LPA met with Program Manager, Cristina Williams, and at this time the reason for the visit was explained. Entrance interview.

At 9:01 a.m., the LPA along with the Program Manager 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.

KITCHEN: The LPA inspected the kitchen/food service area at 9:18 a.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates. The knives and sharps were observed in a locked drawer inaccessible to residents in care. Cleaning solutions were observed locked and inaccessible under the kitchen sink. At 9:20 a.m., the hot water temperature was measured in the kitchen sink, and it measured 110.8 degrees Fahrenheit.

COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. The smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were observed to be fully charged on 02/16/2024.

Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

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: CARMEL HOME	FACILITY NUMBER: 565802469
	VISIT DATE: 06/03/2024

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Continued from LIC 809...

LPA observed required postings throughout the common space. There is a working telephone on premises. Working auditory alarms were observed at the time of the visit. Different activities for resident use were observed by the living room. There is a closet by the hallway designated with additional activities for residents. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station.

GARAGE: The garage is attached and inaccessible to residents in care. The facility has a sufficient amount of emergency food and water. LPA observed a sufficient supply of Personal Protection Equipment (PPE). The washer and dryer were observed inside the garage. Detergents and cleaning solutions were observed in the garage locked and inaccessible at the time of the visit.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There was one (1) gate that self-latches. No bodies of water were noted at the time of the visit.

BEDROOMS: There are four (4) resident bedrooms. LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPA observed additional clean linens and towels in a hallway closet for resident use.

RESTROOMS: There are two (2) restrooms designated for resident use. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured in both bathrooms. The first bathroom measured 109.4 degrees Fahrenheit at 9:05 a.m.; and the second bathroom measured 106.3 degrees Fahrenheit at 9:11 a.m.

Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

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: CARMEL HOME	FACILITY NUMBER: 565802469
	VISIT DATE: 06/03/2024

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Continued from LIC 809C...

RECORDS: Records review began at 9:35 a.m.; four (4) resident records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan/individual program plan. All records were complete.

Three (3) personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were complete.

The facility is vendored by Tri-Counties Regional Center (TCRC).

The last disaster drill was conducted on 05/22/2024.

During today’s visit, LPA obtained copies of the Personnel Report LIC 500, Client Roster LIC 9020, and Certificate of Liability Insurance.

MEDICATIONS: Medications review began at approximately 12:45 p.m.; medications are centrally stored by the nurse’s station in a locked cabinet. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appeared to be given as prescribed at the time of the visit.

Exit interview. Report was reviewed and a copy was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

LIC809 (FAS) - (06/04)

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