565850388-9-16-2024-29-AS-ECOZ-D96TD8-20240916143755

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850388
Report Date: 09/16/2024
Date Signed: 09/16/2024 02:38:37 PM

Document Has Been Signed on 09/16/2024 02:38 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	REESEJOY CARE HOME III		FACILITY NUMBER:	565850388
ADMINISTRATOR/ DIRECTOR:	VINCECRUZ, SUSANA		FACILITY TYPE:	740
ADDRESS:	1013 N SIXTH STREET		TELEPHONE:	(805) 832-4923
CITY:	PORT HUENEME	STATE: CA	ZIP CODE:	93041
CAPACITY: 6		CENSUS: 6	DATE:	09/16/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Roberto Ramirez-Facility Manager		TIME VISIT/ INSPECTION COMPLETED:	02:45 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	At 10:30 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted a pre-licensing visit to the above noted facility. The LPA met with applicant representative, Roberto Ramirez. This is a a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver for six (6) has been requested. Component III was completed during the inspection with the applicant. The facility is a single story home. At 12:00 PM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing the home for six (6) non-ambulatory residents in rooms #1-4. The facility has two (2) private bedrooms and two (2) shared bedrooms. Bedroom #2, #3 and #4 have direct access outside. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with comfortable mattress and clean linen; which includes, top and bottom linens, pillowcases, blanket and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with wheelchair or walker. All rooms were free of odors. All window screens were clean and maintained in good repair. The LPA observed a makeshift staff room in the passageway leading to the garage. Upon observation, the beds and other items in the makeshift staff room were removed. Applicant representative understands that the facility does not have a staff room, therefore will have 24 hour awake staff and cannot have staff sleep in the facility including the garage unless there is an approved staff room. There is two (2) common restrooms. Both resident bathrooms have showers with grab bars and non-skid materials. The hot water temperature was measured as follows: resident's common bathroom outside of room #4 117.9F, common restroom outside of rooms #1 and #2 117.1F which fall within the allowable range of 105F to 120F. Report continued on LIC 809-C (2ND PAGE).

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

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: REESEJOY CARE HOME III	FACILITY NUMBER: 565850388
	VISIT DATE: 09/16/2024

NARRATIVE

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Resident and staff records are stored in a locked drawer in the office. Medications are centrally stored in a locked closet located in the entryway of the facility. Knives and cleaning supplies are stored in a locked drawer and cabinet in the Kitchen. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The first aid supplies were complete, including a thermometer and a current version of a first aid manual.

The supply of perishable and nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in the locked garage. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. The facility has televisions, puzzles, games and coloring books for activities. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non-private bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. The facility has emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and they have an A/C unit and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. At 12:16 PM the smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There is one (1) fire extinguisher in the kitchen, fully charged and do not exceed the purchase date 09/15/2024. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate. There is a functioning telephone on the premises. The emergency exiting plans/sketch, emergency telephone numbers and other required postings are posted in the entry way of the home.

Report continued on LIC 809-C (3RD PAGE).

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

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: REESEJOY CARE HOME III	FACILITY NUMBER: 565850388
	VISIT DATE: 09/16/2024

NARRATIVE

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The exterior passageways were clean and clear of any obstructions. There is a covered patio area with outdoor seating. The back and sides of the house are separated from the front yard by gates on each side. The garage is accessible from the house; the garage door is to remain locked from the inside of the house. The LPA observed a bed in the garage which was discussed with the applicant. Infection control practices were discussed with the applicant.. Facility has a 30 day supply of Personal Protective Equipment (PPE) on site.

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 report issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

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