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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850530
Report Date: 08/21/2024
Date Signed: 08/21/2024 01:51:17 PM

Document Has Been Signed on 08/21/2024 01:51 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:CHANNEL ISLANDS HOMEFACILITY NUMBER:
565850530
ADMINISTRATOR/
DIRECTOR:		BARRETTO, CLEOFE SFACILITY TYPE:
740
ADDRESS:941 GILL AVETELEPHONE:
(805) 827-3651
CITY:PORT HUENEMESTATE: CAZIP CODE:
93041
CAPACITY: 6CENSUS: DATE:
08/21/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Cleofe S Barretto/Arlene MartinezTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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At 10:00 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted a pre-licensing visit to the above noted facility. The LPA met with applicants, Cleofe S Barretto and Arlene Martinez. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver for three (3) has been requested. Component III was completed during the inspection with the applicants.

The facility is a single story home. At 12:05 PM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing the home for five (5) non-ambulatory residents in rooms #2, 3, and 4 and one (1) bedridden resident in room #1. The facility has two (2) private bedrooms and two (2) shared bedrooms. Bedroom #1 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. In addition, no bedroom was used as a passageway to another room, bath or toilet. The facility does not have a staff room, therefore will have 24 hour awake staff. All rooms were free of odors. All window screens were clean and maintained in good repair.

There is one (1) common restroom in the hallway and one private restroom in bedroom #4.Both resident bathrooms have showers with grab bars and non-skid materials. The hot water temperature was measured as follows: resident’s private bathroom in room #4 = 111.7 *F, and resident's common bathroom 111.9*F and the kitchen – 110.7 *F, which fall within the allowable range of 105*F to 120*F.

Report continued on LIC 809-C (2ND PAGE).
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
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 3
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: CHANNEL ISLANDS HOME
FACILITY NUMBER: 565850530
VISIT DATE: 08/21/2024
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Resident and staff records will be stored in a locked filing cabinet in the closet located in the hallway. Medications will also be centrally stored in a locked filing cabinet in the closet located in the hallway. Knives and cleaning supplies will be stored in locked cabinets 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 was a three day supply of emergency water. 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 a locked cabinet located in the garage. No flies or other vermin were observed.



The common areas were appropriately furnished, and the lighting was adequate. The facility has televisions, puzzles, coloring books, books and games 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 ceiling fans, floor fans, and pedestal fans throughout the home 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 12:32 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 hallway leading to the garage, fully charged and do not exceed the purchase date 05/16/2024. 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: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: CHANNEL ISLANDS HOME
FACILITY NUMBER: 565850530
VISIT DATE: 08/21/2024
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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 doors were locked from the inside of the house. 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: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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