198600334-6-26-2023-28-AS-AGOZ-CT6VBR-20230626161758

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600334
Report Date: 06/26/2023
Date Signed: 06/26/2023 04:18:05 PM

Document Has Been Signed on 06/26/2023 04:18 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	OXFORD VILLA		FACILITY NUMBER:	198600334
ADMINISTRATOR:	CHERTOK, VLADIMIR		FACILITY TYPE:	735
ADDRESS:	223 NORTH OXFORD AVENUE		TELEPHONE:	(323) 466-8485
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90004
CAPACITY: 71		CENSUS: 56	DATE:	06/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Margarita Pshenichnaya		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Gonzalez met with Facility Manager Margarita Pshenichnaya and with Facility Administrator Vladimir Chertok explained the purpose for the visit. The facility is licensed to serve mentally disabled adults ages 18-59 years old (Ambulatory Only). All clients in placement are ambulatory. There are currently (56) clients in the facility. Fire drills are conducted monthly and the last fire drill was on 5/2023. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical Services, Disaster Preparedness, and Emergency Intervention. During the visit LPA observed the following: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Per Facility Manager all facility clients have COVID-19 vaccines including boosters. Per Facility Manager all staff also have the COVID-19 vaccines including boosters. Facility Manager and all facility staff are adhering to infection control requirements. Refer to LIC 809C for continuation of report

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OXFORD VILLA	FACILITY NUMBER: 198600334
	VISIT DATE: 06/26/2023

NARRATIVE

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Operational Requirements: Fire Drills are conducted monthly, the last fire drill was conducted on 5/12/23. Emergency Disaster/ Earthquake Drills are also conducted monthly and the last one was conducted on 5/12/23. Facility Manager is adhering to operational requirements.

Physical Plant & Environment Safety: The facility is a two story building and consists of 15 client rooms in the first floor and 21 client rooms located in the second floor, Staff office, Medication room, dining room, laundry room and kitchen. Client rooms include private restrooms. LPA and Facility Manager toured the facility's physical plant inside and outside to ensure there are no health and safety hazards. LPA toured the common areas, client rooms, kitchen, dining area, public restrooms and outside patio/ smoking area. All common areas were properly furnished and appeared comfortable. All client rooms that were inspected have private restrooms. All client bedrooms had the required furniture for comfort and safety and had sufficient lighting. All indoor and outdoor passages were free of obstruction. All bathrooms were observed to be clean and had the required hygiene items. Bathrooms all have a supply of hand soap and paper towels. Linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents. The hot water temperature measured 119 F, which is within the required 105 - 120 degrees. There are no large bodies of water on the premises such as pools. or ponds The grounds are well groomed and there were no hazards observed. Cleaning supplies are inaccessible to clients. The front exterior of the facility is clear of debris with steps leading up to the facility main entrance. Trash containers were observed to have covered lids. There are no security bars nor weapons on the premises. Washer/dryer machines for client and staff use were observed to be in operable condition. LPA observed the facility to be in good repair. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Exits were marked with signs. Notifications and postings were observed which included personal rights, facility sketch, visitor policy, complaint procedures, menu and emergency disaster plan.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and S1-3. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file.

Refer to LIC 809C for continuation of report

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OXFORD VILLA	FACILITY NUMBER: 198600334
	VISIT DATE: 06/26/2023

NARRATIVE

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Client Rights-Information: Client personal rights and House Rules are posted. Per Facility Manager, facility provides wi-fi services to all clients which clients utilize through their personal cell phone.

Client Records-Incident Reports: LPA reviewed Client files for C1 through C3. Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights.

Food Service: The facility has sufficient food supplies of 2-day perishable and 7 day supply of non-perishable items. The food is properly stored in the refrigerator which is clean and well-maintained. There are no clients with special diets residing at this facility. Kitchen is kept clean and free from rodents and other bugs/ insects. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1 through C3. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly.

Incidental Medical Services: Per Facility Administrator, there are no clients at this home with incidental medical services nor any client that has a restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan readily accessible.

Emergency Intervention : Not-Applicable.

No deficiencies noted. Exit interview and a copy of this report was provided to Facility Manager Margarita Pshenichnaya.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

LIC809 (FAS) - (06/04)

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