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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850307
Report Date: 01/28/2025
Date Signed: 01/28/2025 05:01:03 PM

Document Has Been Signed on 01/28/2025 05:01 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:CONEJO VALLEY HOME CAREFACILITY NUMBER:
565850307
ADMINISTRATOR/
DIRECTOR:		FITZGERALD, KEVINFACILITY TYPE:
740
ADDRESS:2476 DRAYTON AVETELEPHONE:
(805) 418-7646
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 6DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Melissa ShubinTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual inspection at 11:55AM. The LPA was greeted by staff and informed them of the reason for the visit. Incoming Administrator Melissa Shubin arrived at 12:34PM. Entrance interview conducted.

Beginning at 11:59AM, the LPA and the staff 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:

BEDROOMS: The facility contains 5 (five) bedrooms for resident use. 4 (four) rooms are designated for private use and 1 (one) is a shared room. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There was a linen closet in the hallway with extra towels and linens.

BATHROOMS: Bathrooms were clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The bathrooms were sufficiently stocked with soap and paper towels. Hot water temperature was measured in both resident restrooms and was within the required range.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature throughout the visit. Hardwired combination smoke and carbon monoxide detectors were tested at 04:01PM and were operational at the time of the visit. The LPA observed required postings throughout the common space. The washer and dryer are located in a laundry room next to the medication closet. The laundry room is locked and inaccessible to residents in care.

KITCHEN: Knives and cleaning supplies are stored locked and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable foods and non-perishable food. The fire extinguisher was fully charged and purchased on 11/24/2024.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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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Document Has Been Signed on 01/28/2025 05:01 PM - It Cannot Be Edited


Created By: Kelly Dulek On 01/28/2025 at 04:06 PM
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: CONEJO VALLEY HOME CARE
FACILITY NUMBER: 565850307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(i)
Reappraisals
(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out of 5 resident files reviewed did not contain a reappraisal/needs and service appraisal which poses a potential health and personal rights risk to persons in care.
POC Due Date: 02/11/2025
Plan of Correction
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Incoming Administrator agreed to complete LIC 625 form for all residents in care, review the form with the resident and/or their responsible person, and submit copies of the signed forms to CCL 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: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


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: CONEJO VALLEY HOME CARE
FACILITY NUMBER: 565850307
VISIT DATE: 01/28/2025
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OUTDOOR AREA/GARAGE: The backyard has a covered outdoor area equipped with furniture for resident use. There is a side gate for resident use and is single-latched. The backyard contains a hot tub, which was observed to be covered and inaccessible to residents. There is also a bird bath in the backyard, however residents are supervised while in the backyard and no current residents have been identified to be at risk with access to the smaller water feature. The garage is attached to the property and is locked and inaccessible to residents. Cleaning supplies and disinfectants are stored locked in the garage, as well as extra food and emergency supplies.

RECORDS: Records review began at 12:42PM. Residents’ records were reviewed for, but not limited to: care plans, medical records, admissions agreement, consent forms. 5 (five) of 5 (five) resident records reviewed were missing the needs and service appraisal (reassessment). Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. 5 (five) of 5 (five) staff files reviewed contained all required documents.

MEDICATIONS: Medications review began at 02:52PM. Medications are centrally stored and locked in a closet next to the laundry room; medications are labeled and were checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record form. No errors observed during the medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's Emergency Disaster Plan, which was observed to be complete and updated annually as required. LPA noted the facility staff are aware of and following Infection Control policies and procedures, but did not have a written Infection Control Plan. Incoming Administrator completed the document during today's visit. Emergency disaster drills are conducted at minimum quarterly, with the last documented drill on 12/19/2024.

The LPA reviewed the following documents:


- LIC500 Personnel Report
- LIC9020 Client Roster
- Liability Insurance

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC809-D).
Exit interview conducted, appeal rights discussed, and a copy of this report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
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