565850073-10-1-2024-29-AS-VCOY-D9N2BE-20241001171502

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850073
Report Date: 10/01/2024
Date Signed: 10/01/2024 05:15:10 PM

Document Has Been Signed on 10/01/2024 05:15 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	OCEAN BREEZE AT BLUE OAK		FACILITY NUMBER:	565850073
ADMINISTRATOR/ DIRECTOR:	RAYAS, EVELYN		FACILITY TYPE:	740
ADDRESS:	1132 BLUE OAK ST		TELEPHONE:	(805) 482-7082
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY: 6		CENSUS: 6	DATE:	10/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Evelyn Rayas		TIME VISIT/ INSPECTION COMPLETED:	12:30 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) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 09:15 A.M. LPA initially met with facility staff, Gerardo Gonzalez. Administrator Evelyn Rayas was contacted and arrived shortly after the visit began. Entrance interview conducted. Beginning at 09:45 A.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 facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers are fully charged and last serviced on 05/10/2024. Hardwired combination smoke detectors and fire doors were tested at 10:15 A.M., separate carbon monoxide detector was tested at 10:18 A.M. and all were functional at the time of the visit. No fire clearance concerns were observed. KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food as well as emergency food. Cleaning supplies are located in a locked cabinet under the kitchen sink. Knives and sharps are locked in a separate kitchen drawer next to the dishwasher. LPA observed them to be locked and properly stored at the time of the visit. At 9:52 A.M. hot water temperature measured at 117.9 degrees Fahrenheit. COMMON AREAS: In the common areas, including dining room and living room, walls and flooring were checked for cleanliness and good condition. At the time of the visit, furniture was observed to be in good condition. The LPA observed the required postings in the common area. LPA observed the fireplace in the living room, which was adequately screened. Auditorial signal was observed in each door around the facility. Facility maintained a comfortable temperature of 71 degrees. Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OCEAN BREEZE AT BLUE OAK	FACILITY NUMBER: 565850073
	VISIT DATE: 10/01/2024

NARRATIVE

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Continued from LIC 809

BATHROOMS: There are three (3) bathrooms for resident use. One (1) shared half bathroom was observed in the hallway, two (2) full bathrooms with walk-in showeres are designated for resident use, Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in all three (3) bathrooms and measured in compliance with regulation.

BEDROOMS: There are six (6) total bedrooms in the facility; five (5) bedrooms are designated for resident use. Four (4) are for single occupancy and one (1) is a shared room. LPA observed one (1) staff room which was locked at the time of the visit. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

GARAGE: Garage was observed locked and contained laundry area, extra food, PPE and incontinence supplies, and emergency food and water. Cleaning compounds were stored in cabinets surrounding the washer and dryer and separately from food supplies.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. Both side gates were observed with self-latching mechanism and operational at the time of the visit. All passageways were observed to be clear. There were no bodies of water on the premises.

RECORD REVIEW: Began at 10:35 AM. Staff and resident 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, and personal rights. All five (5) staff files including the Administrator and six (6) resident files observed were observed to be in compliance with regulation. All training was observed to be complete.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OCEAN BREEZE AT BLUE OAK	FACILITY NUMBER: 565850073
	VISIT DATE: 10/01/2024

NARRATIVE

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Continued from LIC 809-C

MEDICATION REVIEW: Medications are kept in a locked kitchen cabinet. Additionally, inside the locked cabinet facility has resident’s records and a complete First Aid kit with a manual. Began at 12:15 P.M. Medications for six (6) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

INTERVIEWS: During today's visit, LPA interviewed two (2) staff and one (1) resident.

LPA obtained Client Roster, Staff Roster, and Liability insurance. Last emergency drill was conducted on 07/05/2024.

LPA reviewed facility’s Emergency Disaster Plan. Plan was in compliance with regulations at the time of the visit.

No deficiencies cited at this time. Exit interview conducted. Report issued and provided to Administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

LIC809 (FAS) - (06/04)

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