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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609818
Report Date: 11/18/2024
Date Signed: 11/18/2024 02:42:30 PM

Document Has Been Signed on 11/18/2024 02:42 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 HOME 1, THEFACILITY NUMBER:
567609818
ADMINISTRATOR/
DIRECTOR:		ALARCON, ESTRELLAFACILITY TYPE:
740
ADDRESS:705 CAMINO CONCORDIATELEPHONE:
(805) 383-4668
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 6DATE:
11/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Estrella AlarconTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:00 A.M. LPA met with Licensee/Administrator Estrella (Lillian) Alarcon. Entrance interview conducted.

Beginning at 10:20 A.M., the LPA, along with Licensee/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:

Hardwired combination smoke and carbon monoxide detectors were tested at 11:00 A.M. and were functional at the time of the visit. Fire extinguishers was observed to be fully charged and purchased on 08/12/2024.

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 and 1 (one) designated for staff use.

RESTROOMS: The LPA observed 6 (six) restrooms in the facility. 5 (five) are for resident use and 1 (one) is designated for staff use only. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Between 10:35 A.M. and 10:45 A.M. hot water temperature was measured in all resident restrooms. Four (4) restrooms measured within the required range, however restroom next to room # 6, measured 131.3 degrees Fahrenheit. LPA did not check hot water temperature in the staff restroom.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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Document Has Been Signed on 11/18/2024 02:42 PM - It Cannot Be Edited


Created By: Valeria Conway On 11/18/2024 at 02:21 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: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one (1) resident restroom and the kitchen hot water measured at above required 120 *F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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Administrator will adjust thermostat and complete a 7 day water log and submit to LPA by 11/25/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


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: ESTATE HOME 1, THE
FACILITY NUMBER: 567609818
VISIT DATE: 11/18/2024
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COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. Two (2) fireplaces were observed to be adequately screened. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 73 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed.

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. LPA conducted a review of expiration dates on product labels. At 10:48 A.M. hot water was measure at 128.4 degrees Fahrenheit.

OUTDOOR SPACE: The backyard is shared between this facility and another related facility. The shared yard has a covered outdoor area equipped with furniture for resident use. The facility does have a fountain, but it was observed to be empty at the time of the visit.

GARAGE/LAUNDRY ROOM: Adjacent to the staff room is a garage. LPA observed a washer and dryer. Garage remains locked. Garage contains cleaning, incontinence products, and PPE supplies as well as storage. Garage is shared with related facility.

RECORD REVIEW: Between 11:15 A.M. and 12:35 P.M., Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Six (6) resident records reviewed were complete and contained all required documents. Three (3) staff files reviewed were complete and contained all required documents.

EMERGENCY DISASTER PLAN: Facility was evacuated on 11/06/2024 due to the “Mountain Fire”. During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to emergency disaster plan are adequate, complete, and updated annually, as required. Emergency drills are conducted monthly, with the last drill documented on 11/02/2024.

Continued from LIC 809

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

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
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: ESTATE HOME 1, THE
FACILITY NUMBER: 567609818
VISIT DATE: 11/18/2024
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Continued from LIC 809-C

INTERVIEWS: Throughout the visit, LPA interviewed 2 (two) staff and 1 (one) resident.

MEDICATION REVIEW: At 1:15 P.M. medications for six (6) residents were observed. All residents' prescription medications were observed to be maintained and administered in compliance with regulation.

During today's visit, LPA gathered the following items: Personnel Records (LIC 500), Current certificate of insurance, Resident Rooster (LIC 9020).

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

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

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC809 (FAS) - (06/04)
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