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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850097
Report Date: 10/05/2022
Date Signed: 10/05/2022 12:47:54 PM

Document Has Been Signed on 10/05/2022 12:47 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 HAVENFACILITY NUMBER:
565850097
ADMINISTRATOR:CATABAY,ERIKA GRACEFACILITY TYPE:
740
ADDRESS:154 CAMINO CASTENADATELEPHONE:
(805) 512-0102
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 6DATE:
10/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Grace CatabayTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 10:14AM. This annual had a specific emphasis on infection control practices and procedures. The LPA initially met with facility staff and discussed the reason for the visit. Licensee Representatives/Administrators Grace and Teddy Catabay arrived at 10:35AM. Entrance interview conducted.

The LPA, along with facility Licensee Representative Grace Catabay, 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:

Fire Extinguisher was observed to be fully charged and purchased on 11/24/2021. Hardwired smoke detectors and separate carbon monoxide detector were tested at 10:49AM and were functional at the time of the visit.

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 was adequately screened.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The facility laundry room and garage were 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.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2022
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: 10/05/2022
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(Continued from LIC 809)

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.

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. Water temperature was measured in both resident restrooms and measured at 139.0 degrees Fahrenheit at 10:44AM in the shared resident restroom and after adjusting the water heater, measured at 131.8 degrees Fahrenheit at 12:03PM in the same restroom and 122.6 degrees Fahrenheit at 12:08PM in the private resident restroom.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee Representative/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. 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

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit interview conducted with Grace Catabay. Today’s reports and appeal rights were reviewed and provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2022 12:47 PM - It Cannot Be Edited


Created By: Kelly Dulek On 10/05/2022 at 11:55 AM
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: CAMARILLO HAVEN
FACILITY NUMBER: 565850097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 as water temperature measured at 139.0 degrees Fahrenheit in the resident restroom which poses an immediate safety risk to persons in care.
POC Due Date: 10/19/2022
Plan of Correction
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Water temperature was turned down during the visit, and measured at 110.0 degrees Fahrenheit prior to LPA leaving the facility. Licensee purchased a new thermometer for use at the facility and will record water temperatures daily for a week and send the log to LPA by POC due date.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022


LIC809 (FAS) - (06/04)
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