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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850355
Report Date: 10/20/2023
Date Signed: 10/20/2023 06:00:34 PM

Document Has Been Signed on 10/20/2023 06:00 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:HERITAGE HOME CARE LLCFACILITY NUMBER:
565850355
ADMINISTRATOR:PACHECO, ONYX ONASINFACILITY TYPE:
740
ADDRESS:390 FULTON STREETTELEPHONE:
(805) 824-2500
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 0DATE:
10/20/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Onyx Pacheco, Grace Onasin, & May ReyesTIME COMPLETED:
06:07 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing visit to this property at 01:00PM. LPA met with applicant representatives Onyx Pacheco, Grace Onasin, and May Reyes. The applicant has obtained fire clearance for six (6) bedridden with a total capacity of six (6) residents. The proposed facility has a pending Dementia care plan and a pending hospice care waiver for two (2) residents. Applicant completed component II interview on 10/03/2023. During today's visit, Applicant representatives completed component III with the LPA.

Beginning at 01:48PM, LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired combination smoke alarm and carbon monoxide detectors and fire doors were tested at 02:19PM and function properly at this time. Sprinkler system was tested during the fire inspection and functioned properly. Two (2) fire extinguishers were observed to be fully charged and recently purchased. 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 properly screened fireplace was observed in the living room. A telephone is present, phone line will be connected, and Licensee representative will inform CCL of the phone number prior to licensure.

The proposed facility has four (4) bedrooms total, of which two (2) are private rooms and two (2) are designated for shared resident use. All bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have appropriate linens. There is also an ample supply of linen, towels and paper products. The proposed facility has two (2) bathrooms, one (1) is designated for staff and one (1) for resident use. LPA observed night-lights were present in the hallways. Hot water initially measured at 123.5 degrees Fahrenheit. Water temperature was adjusted during the visit, LPA retested the water, and it measured within the required range prior to the end of the visit.

Report Continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: HERITAGE HOME CARE LLC
FACILITY NUMBER: 565850355
VISIT DATE: 10/20/2023
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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 emergency water. Knives were stored in a locked drawer and cleaning supplies are stored locked under the sink. Adjacent to the kitchen is a laundry area, containing locked cabinets for chemical storage. A locked medication cabinet was observed, as well as a locked cabinet designated for record storage. First aid kit was observed.

Building and grounds were observed. Patio area contains a shaded seating area for future resident use. A detached garage was observed to be locked and inaccessible to future residents. 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. During the visit, both gates were being worked on and LPA observed one gate to be self-closing and self-latching prior to the end of the visit.

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


1. Both gates need to be self-closing and self-latching.
2. A working telephone line needs to be present.

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: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC809 (FAS) - (06/04)
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