Most inspections found no deficiencies, with the facility generally maintaining clean and safe living and common areas. The most recent inspection on January 28, 2025, cited a single deficiency for missing reappraisal and service appraisal documentation in resident files, which posed a potential health and personal rights risk. Earlier inspections identified issues with staff night supervision training, incomplete resident appraisals, and missing emergency contact information, some of which involved immediate risk concerns. There were no fines, enforcement actions, or license suspensions noted in the available reports. The record shows some improvement in compliance with training and documentation requirements, though appraisal documentation remains an area needing attention.
The inspection was an unannounced required annual inspection conducted to ensure the facility's compliance with Title 22 Regulations and health and safety standards.
Findings
The facility was generally found to be in compliance with health and safety regulations, with clean and well-maintained bedrooms, bathrooms, common areas, kitchen, and outdoor areas. However, a deficiency was cited for failure to conduct and document reappraisals/needs and service appraisals in 5 out of 5 resident files reviewed, posing a potential health and personal rights risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Licensee did not comply with reappraisal requirements; 5 out of 5 resident files reviewed lacked reappraisal/needs and service appraisal documentation.
The inspection was an unannounced required annual inspection to ensure the facility's compliance with Title 22 Regulations and health and safety standards.
Findings
The facility was generally found to be in compliance with physical plant and safety requirements, including kitchen, bedrooms, bathrooms, common areas, and outdoor areas. However, deficiencies were cited related to staff night supervision training, incomplete resident appraisals, and missing emergency contact information in resident files.
Deficiencies (3)
Description
Two out of two night staff are not trained in first aid as required, posing an immediate health, safety or personal rights risk to persons in care.
Six out of six residents did not have a completed appraisal prior to admission, posing a potential health, safety or personal rights risk to persons in care.
Four out of six resident files did not have a completed emergency contact form, posing a potential health, safety or personal rights risk to persons in care.
Report Facts
Residents missing Identification and Emergency Contact form: 4Residents missing Resident Appraisal form: 5Personnel files missing Health Screening Form: 6Personnel files missing Personnel/Employment form: 1Night staff not trained in first aid: 2Residents without completed appraisal: 6Residents missing emergency contact form: 4
Employees Mentioned
Name
Title
Context
Sandra Urena
Licensing Program Analyst
Conducted the inspection and signed the report
Kasandra Lopez
Licensing Program Manager
Supervisor overseeing the inspection
Melissa Briones
Facility designated staff present during inspection
Kevin Fitzgerald
Administrator
Facility administrator named in report header
Inspection Report Original LicensingCapacity: 6Deficiencies: 0Feb 3, 2023
Visit Reason
A pre-licensing visit was conducted to evaluate the facility for fire safety, personal accommodations and services, and food service in preparation for initial licensing.
Findings
The facility was found to be in compliance with Title 22 regulations at the time of the visit, with all safety equipment functioning properly, adequate accommodations, sufficient supplies, and proper storage of medications and cleaning supplies.
Report Facts
Fire clearance capacity: 6Hot water temperature: 111.2Hot water temperature: 109.4Food supply: 7Capacity: 6Census: 0
Employees Mentioned
Name
Title
Context
Kevin Fitzgerald
Applicant Representative / Administrator
Met with Licensing Program Analyst during pre-licensing visit
Martha Arroyo
Licensing Program Analyst
Conducted the pre-licensing visit and inspection
Desaree Perera
Licensing Program Manager
Named as Licensing Program Manager on report
Inspection Report Original LicensingCapacity: 6Deficiencies: 0Jan 26, 2023
Visit Reason
Initial licensing evaluation of Conejo Valley Home Care Facility to verify applicant/administrator understanding of community care facility licensing laws and readiness for operation.
Findings
The applicant/administrator demonstrated understanding of licensing laws, facility operation, admission policies, staffing, restrictive health conditions, emergency preparedness, complaints reporting, and pre-licensing readiness. No clients were in care at the time of the evaluation.
Report Facts
Capacity: 6Census: 0
Employees Mentioned
Name
Title
Context
Kevin Fitzgerald
Administrator/Corp Member
Met with during evaluation and confirmed understanding of licensing requirements
Jude De La Concepcion
Licensing Program Manager
Named as Licensing Program Manager on report
Marisa Holabird
Licensing Program Analyst
Named as Licensing Program Analyst and signed report
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