567609818-10-22-2021-29-AS-KDUK-C82VXG-20211022164931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609818
Report Date: 10/22/2021
Date Signed: 10/22/2021 04:50:25 PM

Document Has Been Signed on 10/22/2021 04:50 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:	ESTATE HOME 1, THE		FACILITY NUMBER:	567609818
ADMINISTRATOR:	ALARCON, ESTRELLA		FACILITY TYPE:	740
ADDRESS:	705 CAMINO CONCORDIA		TELEPHONE:	(805) 358-3111
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY: 6		CENSUS: 6	DATE:	10/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:39 PM
MET WITH:	Estrella Alarcon		TIME COMPLETED:	03:37 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:39PM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Estrella (Lillian) Alarcon and discussed the reason for the visit.

The LPA, along with facility Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, family room, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area.

The courtyard/backyard has a covered outdoor area equipped with furniture for resident use. LPA observed a large three-tiered fountain in the courtyard area. The garage was observed locked and contained the laundry area, as well as emergency food supply and water, and storage. The licensee is currently converting a portion of the garage into a staff bedroom, office, and bathroom. Licensee stated plans have been submitted to and approved by CCLD.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) total bedrooms for resident use.

RESTROOMS: The LPA observed 5 (five) restrooms in the facility. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

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: ESTATE HOME 1, THE	FACILITY NUMBER: 567609818
	VISIT DATE: 10/22/2021

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INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff and visitors to be wearing masks, however residents are not consistently encouraged to wear face coverings in common areas. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:
- N95 fit testing for all staff

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Civil penalties assessed in the amount of $500.00.

Exit interview conducted, todays reports, civil penalty and appeal rights were reviewed and emailed to the Licensee/Administrator.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/22/2021 04:50 PM - It Cannot Be Edited

Created By: Kelly Dulek On 10/22/2021 at 02:56 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ESTATE HOME 1, THE	FACILITY NUMBER: 567609818
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(e)

Care of Persons with Dementia

(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as LPA observed a large fountain in the courtyard area, containing standing/running water which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2021
	Plan of Correction
1 2 3 4	Licensee agreed to add rocks to the fountain to ensure water depth does not pose a hazard to residents in care. Licensee will send photos to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Kristin Heffernan

LICENSING EVALUATOR NAME:

Kelly Dulek

LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC809 (FAS) - (06/04)

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