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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610056
Report Date: 07/06/2021
Date Signed: 07/06/2021 02:44:02 PM

Document Has Been Signed on 07/06/2021 02:44 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:APPLEGATE @ BERKSHIREFACILITY NUMBER:
567610056
ADMINISTRATOR:CARMONA, RUBENFACILITY TYPE:
740
ADDRESS:2010 FULLBROKE DRIVETELEPHONE:
(805) 207-7790
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY: 6CENSUS: 4DATE:
07/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ken Pineda, CaregiverTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required annual visit at 12:30PM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Caregiver Ken Pineda and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 108.9 Fahrenheit at 12:56PM.
BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings and sufficient lighting.
RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. Restroom one (1) hot water measured 110.1 Fahrenheit at 01:01PM. Restroom two (2) hot water measured 108.7 Fahrenheit at 01:04PM. Restroom two (3) hot water measured 113.4 Fahrenheit at 01:09PM. Restroom two (4) hot water measured 111.4 Fahrenheit at 01:13PM. Restroom two (5) hot water measured 109.9 Fahrenheit at 01:16PM. Restroom two (6) hot water measured 109.8 Fahrenheit at 01:17PM.
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. LPA observed required postings in the hallway. Two fire extinguisher was observed to be fully charged.

shireContinued on LIC 809C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2021
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: APPLEGATE @ BERKSHIRE
FACILITY NUMBER: 567610056
VISIT DATE: 07/06/2021
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BACKYARD: The backyard has multiple covered outdoor areas equipped with furniture for resident use. There were no bodies of water noted. The garage contains additional nonperishable and perishable food, as well as emergency water supply. The garage is attached to the facility.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Caregiver regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. LPA observed an adequate supply of Personal Protection 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 does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

Exit interview conducted. A copy of the report and appeal rights were provided via email..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021
LIC809 (FAS) - (06/04)
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