565850268-8-25-2022-29-AS-JROS-CHMR2T-20220825123852

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850268
Report Date: 08/25/2022
Date Signed: 08/25/2022 12:40:06 PM

Document Has Been Signed on 08/25/2022 12:40 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:	RESIDENCE AT DEAN LLC, THE		FACILITY NUMBER:	565850268
ADMINISTRATOR:	LIMBO, JOSEPHINE		FACILITY TYPE:	740
ADDRESS:	4032 DEAN DRIVE		TELEPHONE:	(805) 654-0580
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY: 5		CENSUS: 0	DATE:	08/25/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Josephine Limbo		TIME COMPLETED:	12:38 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) JoAnn Rosales conducted a pre-licensing visit to the above noted facility. The LPA met with applicant Josephine Limbo. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver for 5 has been requested. Component III was conducted in conjunction with this pre-licensing visit. The facility is a one story. A physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for 5 non-ambulatory residents. The facility has 3 private resident bedrooms, Rooms #1, 3, and 4 and 1 shared room, Room #2. All rooms have direct exits to the outside. The facility does not have fire sprinklers. Room #1 was set up with a bed, night stand, lamp, chests of drawers, chair and closet space. The bed was furnished with a comfortable mattress and clean linen; which includes, top and bottom linens, and pillowcases. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are no staff rooms – awake night staff only - is required. All rooms were free of odors. All window screens were clean and maintained in good repair. There are 2 bathrooms in the hallway. 1 is designated as a staff/visitor bathroom. There is 1 resident bathroom with grab bars, a shower and a non-skid mat. Room #2 has a private sink, and bathroom. Applicant stated that the shower will not be used for the residents. The facility has 1 water heater and the hot water tested in the resident bathroom at 104.2 degrees F. Resident and staff records will be stored in locked cabinets in the office. Medications will be centrally stored in locked cabinets in the office. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in locked cabinets in the office. Continued on 809C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

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: RESIDENCE AT DEAN LLC, THE	FACILITY NUMBER: 565850268
	VISIT DATE: 08/25/2022

NARRATIVE

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The exterior passageways were clean and clear of any obstructions. There is an area shaded by trees in the back of the house with a table and chairs where residents can sit. The back and sides of the house are separated from the front yard by gates. There is no front yard or driveway gate. There are not any bodies of water on the premises at the present time.

The garage is not accessible from the house; the garage door was closed.

The following items must be corrected prior to licensure. Submit proof of corrections, along with a copy of this report, to LPA Rosales, so that your application may be completed: Both backyard side gates self-closing, sufficient supply of blankets, and complaint poster 20” x 26” in size posted in the main entryway of the facility.

This report will be sent to the Centralized Application Bureau (CAB) once all corrections are received. You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

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: RESIDENCE AT DEAN LLC, THE	FACILITY NUMBER: 565850268
	VISIT DATE: 08/25/2022

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Kitchen knives are stored in a locked drawer in the kitchen. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at 0 degrees F. and the refrigerator was maintained at 40 degrees F. The supply of nonperishable food is adequate. There are no pesticides, poisons or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen and house cleaning supplies are stored in a locked cabinet under the kitchen sink. Laundry supplies are kept in a locked cabinet under the staff/visitor bathroom sink. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There is a television in the living room and other entertainment equipment, games and activity supplies in the office. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non-private bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is not a fireplace in the living room. The physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There are 2 fully charged fire extinguishers throughout the house. The laundry area is located in the laundry room next to the office. The supply of extra bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a locked cabinet in staff/visitor bathroom. Extra incontinence supplies are stored in the garage. There is a functioning telephone on the premises. The emergency exiting plans/sketch is posted in the office. The emergency telephone numbers are posted in the office. Other required postings are posted in the office.

Continued on 809C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

LIC809 (FAS) - (06/04)

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