565850324-8-22-2024-29-AS-VCOY-D8DMBR-20240822092822

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850324
Report Date: 08/21/2024
Date Signed: 08/22/2024 09:28:34 AM

Document Has Been Signed on 08/22/2024 09:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MALI'S PLACE I		FACILITY NUMBER:	565850324
ADMINISTRATOR/ DIRECTOR:	JACKSON, SARA		FACILITY TYPE:	740
ADDRESS:	68 CAMINO CASTENADA		TELEPHONE:	(818) 274-1809
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY: 6		CENSUS: 3	DATE:	08/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:50 AM
MET WITH:	Sara Jackson		TIME VISIT/ INSPECTION COMPLETED:	02:30 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) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:50 A.M. When the LPA arrived, there were two (2) staffs and three (3) clients present. The LPA was greeted by Caregiver Fidel Francisco and informed the reason for the visit. Caregiver contacted the Administrator by phone, Sara Jackson. At 10:10 A.M., Administrator arrived at the facility. At 10:15 A.M., the LPA conducted a tour of the physical plant with Administrator, to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The following was observed: Kitchen: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives were observed to be locked in a kitchen drawer. At 10:17 A.M. hot water temperature measured at 116.9 degrees Fahrenheit. Fire extinguisher is fully charged, and recently purchased on 08/02/2024. Combination smoke alarms and carbon monoxide detectors were tested at 10:49 A.M. and were operational at this time. 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 private bedrooms and one is designated as a shared room. LPA observed trash cans with out tight-fitted lids. No bedroom was used as a passageway to another room, bath, or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. Continues on LIC 809

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MALI'S PLACE I	FACILITY NUMBER: 565850324
	VISIT DATE: 08/21/2024

NARRATIVE

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Continued from LIC 809

Restrooms: The LPA observed four (4) restrooms in the facility; two (2) are shared resident restrooms, one (1) is a private restroom, and one (1) half bath is designated for staff and visitor use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in the common resident restrooms and was within the required range.

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. The facility maintained a comfortable temperature of 75 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities.

Outdoor Space: The backyard area contains a shaded area with a table and chairs for resident use. There is a non-functioning fountain, which was observed to be empty at the time of the visit. Passageways were observed to be clear and free of hazards. There were no bodies of water noted.

Garage/Office: The garage is where the washer and dryer are held, including emergency food and emergency water. Cleaning supplies and disinfectants are kept in locked cabinets in the garage all cleaning compounds were stored in areas separately from food supplies. There is an office area whit a desk and a phone and files are held.

File review: A review of facility files was initiate at 11:45 A.M. and the following was observed. LPA reviewed three (3) residents files and three (3) staff file including the administrator’s. All documents reviewed appeared complete and current. Last fire drill conducted on 05/01/2024. LPA obtained Client Roster, Staff Roster, and Liability insurance.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MALI'S PLACE I	FACILITY NUMBER: 565850324
	VISIT DATE: 08/21/2024

NARRATIVE

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Continued from LIC 809-C

Medication review: Began at 12:30 P.M.; medications are centrally stored and locked under the kitchen counter; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Interviews: Between 1:15 P.M. and 1:45 P.M. the LPA conducted two (2) staff and one (1) residents’ interviews.

No deficiencies cited at this time. Exit interview conducted. Report issued and provided to Administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC809 (FAS) - (06/04)

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