565850255-6-22-2022-29-AS-MARO-CFMUAZ-20220622152534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850255
Report Date: 06/22/2022
Date Signed: 06/22/2022 03:26:24 PM

Document Has Been Signed on 06/22/2022 03:26 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:	CALIFORNIA CARE RCFE BAXTER		FACILITY NUMBER:	565850255
ADMINISTRATOR:	OBTINALLA, MC RICHARD		FACILITY TYPE:	740
ADDRESS:	283 BAXTER STREET		TELEPHONE:	(818) 448-2967
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91320
CAPACITY: 6		CENSUS: 5	DATE:	06/22/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Mc Richard Obtinalla		TIME COMPLETED:	03:30 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) Martha Arroyo arrived at 10:40 a.m. for a pre-licensing inspection. The LPA was scanned and greeted at the door my Licensee Representative, Mc Richard Obtinalla. This is a change of ownership application from California Care RCFE-Baxter #565801398 to California Care RCFE Baxter #565850255. The current census is at 5 residents. The fire clearance was granted on 05/24/2022; in which all rooms were cleared for non-ambulatory. KITCHEN: The LPA observed the kitchen/dining area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed one designated cabinet under the kitchen island where knives and sharps are stored locked and inaccessible to clients. BEDROOMS: There are five (5) bedrooms in the facility; there are four (4) bedrooms for client use, and one (1) staff rooms. The staff rooms are kept locked. Lighting in the rooms appeared adequate. All four (4) client rooms were set up with beds, nightstands, lamps, chests of drawers, chairs, and closet space. BATHROOMS: There are two (2) bathrooms for client use. One (1) out of the four (4) client rooms has an attached bathroom, and the other client bathroom is in the hallway. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in both bathrooms and were in compliance between 105 and 120 degrees Fahrenheit at the time of visit. Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

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: CALIFORNIA CARE RCFE BAXTER	FACILITY NUMBER: 565850255
	VISIT DATE: 06/22/2022

NARRATIVE

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Continued from LIC 809...

COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. The facility smoke alarm system is hard wired; the smoke detectors and carbon monoxide detectors were tested at 10:52 a.m., and operable at the time of the visit. LPA observed one (1) fire extinguisher to be fully charged at the time of visit. Facility has a working landline telephone. All exit doors have functioning auditory alarms. Hallways were free of any obstruction. Emergency exiting plans/sketch, Ombudsmen (LTCO) poster, CCL Poster (LETUSNO), CDSS PINS and emergency telephone numbers are posted in the hallway. In the common areas, walls, flooring, and furniture were checked for cleanliness and were in good condition. The living and dining areas are clean and properly furnished with seating, a table, and television for client use. Main temperature displayed in the hallway read at 76 degrees Fahrenheit. The facility has a central entry point for symptom screening and sanitation station for staff, clients and visitors. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. Staff were observed wearing face coverings. All staff are fully vaccinated and boosted. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

MEDICATIONS: Medications were also observed in a locked cabinet under the kitchen island. First aid kits and manual were observed to be complete.

FILES: Staff and client files are stored locked and inaccessible. All five (5) clients and five (5) staff files were reviewed at 11:50 a.m. and all records were in order.

LAUNDRY: The laundry room is locked adjacent to the kitchen. Cleaning supplies and chemicals are stored and inaccessible to clients.

Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

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: CALIFORNIA CARE RCFE BAXTER	FACILITY NUMBER: 565850255
	VISIT DATE: 06/22/2022

NARRATIVE

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Continued from LIC 809C...

GARAGE AND GROUNDS: The garage is locked and attached to the house. There is one (1) additional refrigerator in the garage with perishable items in good condition. The LPA observed at least a three (3) day supply of emergency water at the time of visit. The backyard has a covered patio area with patio furniture including a table and chairs for client use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. There are no bodies of water on the premises at the time of the visit.

Component III was completed in conjunction with the visit.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA's recommendation for licensure.

Exit interview and report reviewed with Staff, Arnida Obtinalla. A copy of the report was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

LIC809 (FAS) - (06/04)

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