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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606734
Report Date: 11/09/2022
Date Signed: 11/09/2022 10:59:32 AM

Document Has Been Signed on 11/09/2022 10:59 AM - 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., 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:
11/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
07:15 AM
MET WITH:William TanTIME COMPLETED:
09:15 AM
NARRATIVE
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LPA Spaeth conducted an unannounced visit and was greeted by the caregiver and a resident. LPA stated the purpose of the visit was to conduct a case management visit. LPA observed two residents in the facility and two residents had left earlier this morning for work LPA's temperature was recorded. LPA spoke to the two residents and also toured the facility. LPA and Caregiver began the tour at 8:00 am until 8:20 am.

Living room/Kitchen/Dining Room - LPA observed the living room, kitchen, and dining room are all combined. . LPA observed the living room contains comfortable seatin. The kitchen was clean and LPA observed fresh fruit on the counter. The facility contained a two-day supply of perishable foods and a 7 day supply of non-perishable foods. The knives, laundry soap, and cleaning supplies were safely locked under the kitchen cabinet. LPA observed the staff office and observed the medications were locked in a cabinet.

Resident bedrooms. - LPA observed the three resident rooms which contained bed, linens, night stand, lamp, and chest of drawers. The resident bathroom was clean and in working condition.

Upon entering the facility, LPA observed the caregiver was not wearing a mask. LPA reminded caregiver that staff are still required to wear a mask. Based upon LPA's observation, a deficiency is cited on LIC 809-D.

Exit interview conducted, appeal rights discussed, and a copy of the report was given to the caregiver.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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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Document Has Been Signed on 11/09/2022 10:59 AM - It Cannot Be Edited


Created By: Melissa Spaeth On 11/09/2022 at 08:51 AM
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: O-2 HOUSE
FACILITY NUMBER: 197606734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2022
Section Cited
CCR
87470(a)(5)

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Infection Control Requirements. (a) A licensee shall ensure that infection control practices are maintained..: (5) All staff... .. shall practice and maintain respiratory etiquette….to minimize exposure to potential illness. ..
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LPA Spaeth observed Caregiver immediately put on a mask. LPA advised Caregiver that all staff must wear a mask when working at the facility.
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This requirement was not met as evidenced by: Upon entering the facility, LPA observed staff member was not wearing a mask which poses an immediate health and safety risk to residents in care.
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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:Cassandra Harris
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022


LIC809 (FAS) - (06/04)
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