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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850326
Report Date: 08/18/2023
Date Signed: 08/18/2023 02:45:45 PM

Document Has Been Signed on 08/18/2023 02:45 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:MALI'S PLACE IIFACILITY NUMBER:
565850326
ADMINISTRATOR:JACKSON, SARAFACILITY TYPE:
740
ADDRESS:52 CAMINO CASTENADATELEPHONE:
(818) 274-1809
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 0DATE:
08/18/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Sara JacksonTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a Pre-Licensing Inspection with Administrator Sara Jackson. A Change of Ownership Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 11/07/2022. A Fire Clearance was approved on 04/24/2023.

Beginning at 10:58AM, a tour of the physical plant was conducted and the following observed:

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) total bedrooms; 4 (four) are private bedrooms, 1 (one) is a shared room and 1 (one) is designated as a staff room.

RESTROOMS: The LPA observed three (3) restrooms in the facility; two (2) are shared resident restrooms and one (1) is a private restroom. 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. A fireplace was noted and was observed to be adequately screened and inaccessible to residents in care. The LPA observed the required postings in the common area. Medications are stored in a locked cabinet.

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. Fire extinguisher is fully charged, stamped for 2023 and recently purchased. The facility has both smoke detectors and separate smoke detector/carbon monoxide detector, which were tested beginning at 02:22PM and were functional at the time of the visit.

Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2023
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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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: MALI'S PLACE II
FACILITY NUMBER: 565850326
VISIT DATE: 08/18/2023
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GARAGE: The garage was observed to be locked and contained the laundry area, as well as food and water storage, and supply storage.

OUTDOOR SPACE: The backyard area contains a shaded area with a table and chairs for resident use. Exit gate was observed to be self-closing and self-latching. Passageways were observed to be clear and free of hazards.

COMPONENT II/COMPONENT III ORIENTATION: A Component II Orientation was completed telephonically with the Licensee Representative on 07/18/2023. A Component III Orientation was conducted with Administrator during today's visit.



LPA did note that the facility sketches contained in the Application did not match the facility's layout. LPA contacted the Centralized Application Bureau (CAB) analyst to notify them of the discrepancy. LPA also noted that the fire clearance indicates 2 (two) non-ambulatory and 4 (four) bedridden, with a total capacity of 6 (six) residents, however notes at the bottom of the fire clearance do not match the above listed capacity. Additional clarification is required from the fire inspector prior to issuing the license.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating under the new license until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted. A copy of the Licensing Report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023
LIC809 (FAS) - (06/04)
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