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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850097
Report Date: 09/22/2023
Date Signed: 09/22/2023 03:22:21 PM

Document Has Been Signed on 09/22/2023 03:22 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:
09/22/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Erika Catabay & Grace CatabayTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a continuation of the required annual visit at 01:45PM. LPA met with Licensee Representative Teddy Catabay. Additional Licensee Representative Grace Catabay arrived shortly after the visit began. Administrator arrived at the facility during medication review. Entrance interview conducted.

During today's visit, LPA reviewed and observed the following:

INTERVIEWS: Beginning at 01:47PM, LPA interviewed 3 (three) staff and two (2) residents.

EMERGENCY DISASTER PLAN: LPA reviewed the facility's emergency disaster plan, which was recently updated. Emergency drills are conducted quarterly, with the last completed drill documented on 08/18/2023.

INFECTION CONTROL PLAN: During today's visit, LPA reviewed the facility's infection control plan. The facility's policies and procedures related to infection control are adequate.

MEDICATION REVIEW: Began at 02:50PM. Medications for 5 (five) residents were observed. All 5 (five) of 5 (five) residents' medications were observed to be maintained and administered in compliance with regulation.

No citations issued. Exit interview conducted. A copy of today's report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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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