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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606734
Report Date: 11/02/2022
Date Signed: 11/02/2022 02:05:10 PM

Document Has Been Signed on 11/02/2022 02:05 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:O-2 HOUSEFACILITY NUMBER:
197606734
ADMINISTRATOR:CLIFTON VON BUCKFACILITY TYPE:
735
ADDRESS:43956 21ST STREET WESTTELEPHONE:
(661) 729-1000
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 4DATE:
11/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:William TanTIME COMPLETED:
02:15 PM
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On 11/02/2022 at 12:34 p.m. Licensing Program Analyst (LPA), Evelin Rios, conducted an unannounced Annual Required visit at the facility mentioned above. LPA was greeted by Staff #1(S1) William Tan, who granted access to the facility. LPA informed S1 the purpose of the visit and S1 called Administrator Clifton Von Buck who could not meet us at the facility. Administrator gave S1 permission to sign today's report. At approximately, 12:38 p.m. a physical tour was conducted with S1 and LPA observed the following:

Infection control: LPA reviewed the facility mitigation plan (approved on 02/27/2021) to make sure licensee was following current infection control recommendations. Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. Proper signs were observed inside along a wall to the kitchen and in the restroom. Hand sanitizer was also observed. S1 stated they have sufficient PPE supplies for clients and staff.

Kitchen: LPA toured the kitchen area and observed enough supplies of staple non-perishable food for 7 days and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to clients. Cleaning products are kept in a locked cabinet under the kitchen sink. Fire extinguisher was observed by the kitchen to be charged and last serviced on March 22, 2022.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 12:47 p.m. they were tested and observed to be operational. Carbon monoxide detector was observed in the main entry to the kitchen and observed to be functional.

Bedrooms: There are four (4) bedrooms three (3) of which are designated for client use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. One (1) room is for staff.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: O-2 HOUSE
FACILITY NUMBER: 197606734
VISIT DATE: 11/02/2022
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Bathrooms: There are two (2) bathroom one (1) is designated for clients and one (1) in the staff room is only for staff. LPA observed the bathroom to be clean and in good repair. Properly supplied with toilet papers, soap and a hand dryer. The hot water temperature measured at 112.2°F. LPA observed appropriate hand washing signs posted in the bathroom.

Common Area: LPA observed living room and dining room clean and clear of clutter. Furniture was observed to be clean and in good repair. LPA observed a fireplace in the living room closed and not in use. Laundry room is kept locked. Chemicals and detergents are kept locked in laundry room. There is a complete First Aid kit inside the laundry room.

Surrounding Grounds: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There is a hot tub that is not in use or functional and is kept locked.

Medication was observed to be inaccessible and stored in a secured file cabinet in the office area.

No deficiencies cited/ Exit interview conducted / A copy of this report was given.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC809 (FAS) - (06/04)
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