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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850582
Report Date: 01/06/2025
Date Signed: 01/06/2025 03:25:39 PM

Document Has Been Signed on 01/06/2025 03:25 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:ESTATE OF ESTABAN 1, THEFACILITY NUMBER:
565850582
ADMINISTRATOR/
DIRECTOR:		ALARCON, ESTRELLAFACILITY TYPE:
740
ADDRESS:149 ESTABAN DRTELEPHONE:
(805) 358-3111
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 0DATE:
01/06/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Estrella AlarconTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Valeria Conway conducted an announced Pre-Licensing Inspection to the above listed facility. Upon arrival LPA met with Administrator, Estrella “Lillian” Alarcon. Entrance interview conducted.

An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 08/30/2024. A Fire Clearance was approved on 12/02/2024, however further clarification is need it regarding capacity designation. This pending facility has a dementia care program and a pending hospice care waiver for 6 (six) residents.

The proposed physical plant is a one (1) story single family dwelling located in a residential neighborhood of Camarillo, CA. This facility will be housing residents with dementia. There are no client residing in the facility at the moment. This facility doesn’t have a staff room, facility will provide 24/7 care. Administrator will provide an updated facility sketch (LIC 999) changing floor plan to reflect “garage” instead of “staff room”.

The facility consists of six (6) bedrooms. Each bedroom has its own bathroom; however, bathroom located in Room #6 will be shared with staff and visitors. At the time of the visit, LPA informed Administrator that a door is required to separate the bedroom in Room #6 from the shared bathroom. This measure is necessary to ensure the privacy of residents occupying the bedroom.

LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service.

Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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: ESTATE OF ESTABAN 1, THE
FACILITY NUMBER: 565850582
VISIT DATE: 01/06/2025
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Continued from LIC 809

Fire extinguisher is fully charged and recently purchased. Administrator will submit proof of purchase to LPA. Fire alarms/carbon monoxide detectors were tested at 12:37 P.M. and were functional at the time of the visit. LPA observed all required postings on the facility wall, a revised Emergency and Disaster Plan and a Plan of Operation in use.

At 10:30 A.M. a tour of the physical plant was conducted and the following observed:

BEDROOMS: There are six (6) single bedrooms. There was a model furnished bedroom equipped and supplied with appropriate furniture including but not limited to a bed, a chair, a night stan, a lamp and a chest of drawers, bedding, and linens. No client bedroom will be used as a public or general passageway to another room, bath, or toilet. There were no visible hazards or discrepancies observed.

BATHROOMS: LPA observed toilets and handwashing stations to be in operation condition. Solid waste containers are in good repair and have tight-fitting covers. Facility provides each resident privacy and personal accommodations. Additionally, bathrooms had slip resistant mats, however, LPA observed missing grab bars next to the toilets in all bathrooms except for bathroom #6. Water temperatures were measured in all residents’ bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit.



KITCHEN: Appliances and fixtures appeared clean and functional. At the time of the visit, LPA observed a sufficient amount of dining and cookware. Perishable food will be supplied once license is approved. Administrator is aware that food supply shall accommodate a maximum capacity of six (6) residents and facility staff for seven (7) days. Sharps and knives will be stored in locked kitchen drawer. There were no visible immediate hazards observed. Water temperatures measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit.

Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
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: ESTATE OF ESTABAN 1, THE
FACILITY NUMBER: 565850582
VISIT DATE: 01/06/2025
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Continued from LIC 809-C

COMMON AREAS: These include the Family Room, Living Room and Dining Room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. At the time of the visit, LPA observed missing furniture including a dining table. Administrator stated that furniture is schedule to be delivered in the next days. The facility has a fireplace in the family room. At the time of the visit, LPA observed the fireplace not to be properly screened. Administrator will purchase a screen to cover fireplace. There will be a designated cellphone available for resident’s use. Facility will provide internet service for resident use. Facility has enough space to store clean common linen items such as bed sheets, towels, pillowcases, and mattress pads. LPA observed night lights in all hallways and passages. Facility has an auditory signal system in place at the time of the visit. Facility is equipped with two fire doors to enhance safety and prevent the spread of fire. Administrator stated that Fire doors will be closed at all times. At the time of the visit LPA did not observe a magnet to prevent doors from closing.

LAUNDRY ROOM: LPA observed a washer and a dryer machine. Furthermore, LPA observed a locked cabinet where medication will be stored. Facility will properly document medication on the Centrally Store Medication and Destruction log. Additionally, Administrator will use extra cabinets to store facility’s fist aid kit, emergency food and water supplies, staff and residents’ files, non-perishable food, and hygiene products.

SURROUNDING GROUNDS: Garden and yard are easily accessible to residents, and they are sufficient in size, comfortable and appropriately equipped for outdoor use. There was a shaded area with proper furniture for outdoor use. LPA observed two (2) self-closing and latching side gates. LPA observed a non-working creek on the property. At the time of the visit, LPA did not observe water running through the creek. Also, LPA observed an operational water fountain located at the front entrance of the facility. The water fountain was functioning properly at the time of the inspection, and no issues were noted. Additionally, LPA observed sufficient space to accommodate outdoor activities for residents. At the time of the visit, LPA observed construction workers installing railings and gates alongside the backyard. This project shall be completed before licensure. LPA observed video recording cameras facing the outside of the property. LPA explained that if cameras can record sound, administrator shall submit a waiver due to the audio component, to update plan of operation and admission agreement.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
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: ESTATE OF ESTABAN 1, THE
FACILITY NUMBER: 565850582
VISIT DATE: 01/06/2025
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Continued from LIC 809-C

GARAGE: LPA observed a locked garage, which contains emergency disaster supplies and locked chemical storage. Administrator stated that permits to convert part of the garage into a staff room is pending approval from Ventura County officials. LPA explained to Administrator that once permit is approved and construction begins, Community Care Licensing (CCL) shall be informed.


COMPONENT III ORIENTATION: A Component III Orientation was conducted with the Administrator during today's visit.

The following needs to be completed/Photos sent to LPA prior to licensure:

 Door separating bedroom #6 from shared bathroom.
 Install grab bars next to all toilets except for bathroom #6.
 Picture of installed furniture on common areas.
 A screened fireplace.
 Picture of backyard showing finished gates and railings.
 New sketch showing “garage” instead of “staff room.”
 Fire extinguisher’s purchase receipt.


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. A copy of the Licensing Report was issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC809 (FAS) - (06/04)
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