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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850076
Report Date: 10/01/2024
Date Signed: 10/01/2024 05:12:33 PM

Document Has Been Signed on 10/01/2024 05:12 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 BEECHWOODFACILITY NUMBER:
565850076
ADMINISTRATOR/
DIRECTOR:		RAYAS, EVEYLNFACILITY TYPE:
740
ADDRESS:1190 BEECHWOOD STREETTELEPHONE:
(805) 445-6545
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 2DATE:
10/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Evelyn RayasTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 12:40 P.M. LPA met with Administrator Evelyn Rayas. Entrance interview conducted.

Beginning at 12:47 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 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 01:17 P.M., separate carbon monoxide detector was tested at 01:20 P.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. LPA observed them to be locked and properly stored at the time of the visit. During the visit, LPA observed expired food items including 2 salad dressing in the refrigerator. Administrator discarded them immediately. At 1:01 P.M. hot water temperature measured at 110.1 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 74 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.

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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 BEECHWOOD
FACILITY NUMBER: 565850076
VISIT DATE: 10/01/2024
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Continued form LIC 809

BATHROOMS: There are three (3) bathrooms for resident use. Two (2) are designated for shared resident use and one (1) is a private restroom. 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 and one (1) staff 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 is detached from main house. 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 at the time of the visit.

RECORD REVIEW: Began at 01:14PM. 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 two (2) resident files observed were in compliance with regulation. All trainings were 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
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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 BEECHWOOD
FACILITY NUMBER: 565850076
VISIT DATE: 10/01/2024
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Continued from LIC 809-C

MEDICATION REVIEW: Medications are kept in a locked cabinet inside the record and medication room. Additionally, First Aid kit with a manual was observed inside a file cabinet in the desk area adjacent to the kitchen. Began at 2:45 P.M. Medications for two (2) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

LPA obtained Client Roster, Staff Roster, and Liability insurance. Last emergency drill was conducted on 07/04/2024.

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

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

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
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Document Has Been Signed on 10/01/2024 05:12 PM - It Cannot Be Edited


Created By: Valeria Conway On 10/01/2024 at 02:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OCEAN BREEZE AT BEECHWOOD
FACILITY NUMBER: 565850076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having expired food items in the refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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Administrator immediately discarded all expired food items during today's visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024


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