565850097-10-12-2021-29-AS-KDUK-C7QV2T-20211012160340

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850097
Report Date: 10/12/2021
Date Signed: 10/12/2021 04:04:34 PM

Document Has Been Signed on 10/12/2021 04:04 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:	CAMARILLO HAVEN		FACILITY NUMBER:	565850097
ADMINISTRATOR:	CATABAY,ERIKA GRACE		FACILITY TYPE:	740
ADDRESS:	154 CAMINO CASTENADA		TELEPHONE:	(805) 512-0102
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY: 6		CENSUS: 4	DATE:	10/12/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Erika Catabay		TIME COMPLETED:	04:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 2:45PM. This annual had a specific emphasis on infection control practices and procedures. The LPA initially met with facility staff discussed the reason for the visit. Administrator Erika Catabay arrived at 3:20PM. Entrance interview conducted.

The LPA, along with facility Administrator, 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. The following was observed:

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room 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 did not have a screen. Administrator stated the fireplace is not being used, but will obtain a screen for the fireplace.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The facility laundry room was observed to be locked. The outdoor shed was locked and contained the emergency water, PPE supply, and storage.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, as well as emergency supply. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 4 (four) are for resident use and 1 (one) is designated as a staff room.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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: CAMARILLO HAVEN	FACILITY NUMBER: 565850097
	VISIT DATE: 10/12/2021

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(Continued from LIC 809)

RESTROOMS: The LPA observed 3 restrooms in the facility; 2 (two) are designated for resident use and one is a staff restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces.

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. LPA observed all staff and visitors to be wearing masks, however residents are not consistently encouraged to wear face coverings in common areas. The LPA observed an adequate supply of Personal Protective 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’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:
- N95 fit testing for all staff

No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC809 (FAS) - (06/04)

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