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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850332
Report Date: 05/24/2023
Date Signed: 05/24/2023 11:48:16 AM

Document Has Been Signed on 05/24/2023 11:48 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:INFINITY CARE HOMEFACILITY NUMBER:
565850332
ADMINISTRATOR:MANACAP, JOCELYNFACILITY TYPE:
740
ADDRESS:944 BELMONT STREETTELEPHONE:
(805) 415-5316
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 0DATE:
05/24/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Jocelyn ManacapTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing visit to this property at 9:05AM. LPA met with applicant representative Jocelyn Manacap. The applicant has obtained fire clearance for five (5) non-ambulatory and one (1) bedridden (in bedroom #1) for a total capacity of six (6) residents. The proposed facility has a pending Dementia care plan and a pending hospice waiver. Applicant completed component II interview on 04/27/2023. During today's visit, Applicant completed component III with the LPA.

Beginning at 9:18AM, LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired combination smoke alarm and carbon monoxide detectors were tested at 09:45AM and function properly at this time. Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The common living and dining areas are clean and properly furnished. A working telephone is present.

The proposed facility has three bedrooms total, all of which are designated for shared resident use. All bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have sheets, pillows, and mattress pads. There is also an ample supply of linen, towels and paper products. The proposed facility has two (2) bathrooms for resident use, one is a shared bathroom and the other is a private bathroom. LPA observed night-lights were present in the main hallway. Hot water measured at 115.1 degrees Fahrenheit at 9:29AM, which is within the required range.

The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present, as well as, a seven-day supply of water. Knives were stored in a locked drawer and cleaning supplies are stored locked under the sink. Two locked medication cabinets are present in the facility; one is located in the kitchen and a larger one with refrigerator is located in the hallway. First aid kit was observed to be complete.

Report Continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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: INFINITY CARE HOME
FACILITY NUMBER: 565850332
VISIT DATE: 05/24/2023
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The garage was observed to be locked and inaccessible to future residents. The garage contains the laundry area, locked cleaning supplies, emergency food, and storage.

Building and grounds were observed. Patio area contains a step down to the shaded seating area. LPA advised applicant to make the shaded seating area accessible by using a ramp or to relocate the shaded seating area to a more accessible area. The two (2) outdoor exit gates were observed to not be self-closing and self-latching at this time. The applicant was advised that any outdoor gates are not permitted to be locked.

The following needs to be completed/proof submitted prior to the facility being licensed:

  1. Both outdoor gates need to be self-closing and self-latching
  2. The step down into the shaded seating area needs to accessible to residents

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 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 and a copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC809 (FAS) - (06/04)
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