565850418-11-29-2023-29-AS-KDUK-CY2S4P-20231129123304

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850418
Report Date: 11/29/2023
Date Signed: 11/29/2023 12:33:43 PM

Document Has Been Signed on 11/29/2023 12:33 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:	AVANA HOME OF CAMARILLO		FACILITY NUMBER:	565850418
ADMINISTRATOR:	CARBAJAL, JESUSA		FACILITY TYPE:	740
ADDRESS:	574 MURRAY AVENUE		TELEPHONE:	(805) 612-4198
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY: 6		CENSUS: 0	DATE:	11/29/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:07 AM
MET WITH:	Jesusa Carbajal, Amelita Gagarin, Jovilito Gagarin		TIME COMPLETED:	12:35 PM

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Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing visit to this property at 10:07AM. LPA met with applicant representatives Jesusa Carbajal, Amelita Gagarin, and Jovilito Gargarin. The applicant has obtained fire clearance for 4 (four) non-ambulatory, 1 (one) ambulatory, and 1 (one) bedridden with a total capacity of 6 (six) residents. The proposed facility has a pending Dementia care plan and a pending hospice care waiver for 3 (three) residents. Applicant completed component II interview on 11/14/2023. During today's visit, Applicant representatives completed component III with the LPA.

Beginning at 10:19AM, 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 10:49AM and function properly at this time. Fire extinguisher was observed to be fully charged and serviced 09/29/2023.

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 working telephone is present. All required postings were observed in the common area. The facility contains a staff room/office and laundry room. All chemicals and cleaning supplies were observed in a locked hallway cabinet. A locked medication cabinet was observed, as well as a locked cabinet designated for record storage. First aid kit was observed to be complete. Garage was observed to be locked and inaccessible to future residents and contained emergency water and supplies.

The proposed facility has 4 (four) bedrooms total, of which 2 (two) are private rooms and 2 (two) 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 2 (two) bathrooms, 1 (one) is designated for shared resident use and 1 (one) for private resident use. LPA observed night-lights were present in the hallways. Hot water

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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: AVANA HOME OF CAMARILLO	FACILITY NUMBER: 565850418
	VISIT DATE: 11/29/2023

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initially measured at 135.1 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.

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 and cleaning supplies were stored in a locked cabinet under the kitchen sink.

Building and grounds were observed. Patio area contains a seating area for future resident use. Outdoor exit gate was observed to be self-closing and self-latching at this time. All passageways were observed to be clear of any hazards.

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: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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