197606734-11-8-2023-31-AS-ERIS-CXDSF6-20231108124949

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606734
Report Date: 11/08/2023
Date Signed: 11/08/2023 12:49:52 PM

Document Has Been Signed on 11/08/2023 12:49 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 HOUSE		FACILITY NUMBER:	197606734
ADMINISTRATOR:	CLIFTON VON BUCK		FACILITY TYPE:	735
ADDRESS:	43956 21ST STREET WEST		TELEPHONE:	(661) 729-1000
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 4		CENSUS: 4	DATE:	11/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Clifton Von Buck		TIME COMPLETED:	12:50 PM

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On 11/08/2023 at 9:40 a.m. Licensing Program Analyst (LPA), Evelin Rios, conducted an unannounced Annual Required visit at this facility. LPA was greeted by Staff #1(S1), who granted access to the facility. LPA informed S1 the purpose of the visit and S1 called Administrator Clifton Von Buck who informed LPA they will meet LPA at the facility.

At approximately, 10:00 a.m. LPA interviewed Client #1 (C1) who was present at the start of the visit before they went out to the community. At approximately 10:10 a.m. LPA interviewed S1. At approximately 10:25 a.m. LPA and S1 conducted a physical plant tour of the facility and the following was observed:

Infection control: Upon arrival, LPA was asked to sign-in the visitors’ log. Covid-19 signs were observed inside the facility along a wall leading too the kitchen. Hand sanitizer was also observed. S1 stated they have sufficient PPE supplies for clients and staff.

Bedrooms: There are four (4) bedrooms, three (3) of which are designated for client use. LPA observed rooms to be properly furnished, clean and have appropriate bedding and have sufficient lighting. One (1) bedroom is for live-in staff. LPA observed a built in cabinet by the bedrooms with extra linens.

Bathrooms: There are two (2) bathrooms total. One (1) is designated for clients and the other is located in the staff bedroom for staff only. LPA observed the bathroom to be clean and in good repair. Properly supplied with toilet papers, soap and an automatic hand dryer. The hot water temperature measured at 113.4°F at approximately 10:30 a.m.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 10:40 a.m. S1 tested a detector and LPA observed it to be operational. Carbon monoxide detector was observed in the main entry by the kitchen and observed to be functional. (Continued on LIC809-C)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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: 11/08/2023

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(Continued from LIC809)
Kitchen: LPA toured the kitchen area and observed seven day non-perishable supply of food and a two day perishable supply of food; properly stored. All knives and sharps were observed to be double locked in a tool box in a kitchen cabinet under the sink inaccessible to clients. Cleaning products were also observed in the locked kitchen cabinet under the sink. A Fire extinguisher was observed by the kitchen to be fully charged with last serviced date 03/23/23.

Common Areas: 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 not in use and secured with a screen. 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. LPA observed client, staff and medication records locked in the laundry room.

Surrounding Grounds: LPA toured the outside area of the facility. LPA observed a covered patio that provides shade for the clients and appropriate outdoor furniture. There is a hot tub emptied of water, that is not in use and is kept locked.

Client/Staff Records: At approximately 11:11 a.m. LPA reviewed client files to insure compliance of licensing forms. LPA also conducted a file review of staff records to insure forms and training are up to date and in compliance with licensing forms.

Medications: LPA observed medications stored in a secured file cabinet in the office area. At 12:25 p.m. Medications were reviewed for proper storage and documentation. Facility also uses a Medication Administration Record (MAR).

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during this visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC809 (FAS) - (06/04)

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