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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606909
Report Date: 01/04/2024
Date Signed: 01/04/2024 11:23:41 AM

Document Has Been Signed on 01/04/2024 11:23 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:D'WOODSHIRE GUEST HOMEFACILITY NUMBER:
300606909
ADMINISTRATOR:EXPEDITO A. OBLEPIASFACILITY TYPE:
735
ADDRESS:1435 ROSEWOOD AVENUETELEPHONE:
(714) 778-3889
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 6CENSUS: 5DATE:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Jesusa Luis
Mariela Oblepias
Expedito Oblepias		TIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Jesusa Luis. LPA discussed the purpose of the inspection. Licensee Mariela Oblepias arrived at 8:45 a.m. and Administrator (AD) Expedito Oblepias arrived at 9:00 a.m. During the inspection LPA and Staff Luis conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story home with four client bedrooms, two bathrooms, and one staff bedroom. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets but did not have flat sheets; a Technical Advisory was issued on this date. LPA observed all windows were screened. The back yard has a sitting area. LPA observed one staff and five clients present. Common client bathroom was observed to be free of debris and mildew, toilet was operational, bathroom sink is clogged and windowsills were observed to be covered by a thick layer of dust; a Deficiency was cited on today’s date. Water temperature tested at 116.4 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Appliances were all inspected. Sharps were observed locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked. LPA reviewed five client files and observed Needs and Services Plans to be dated from March 2015, dates have been crossed out and annually updated to new date. Needs and Services Plans have not been update and contain the same information from 2015; a Deficiency was cited on today's date. LPA reviewed three staff files and interviewed staff and clients present.

Based on the observations made during today’s inspection, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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 01/04/2024 11:23 AM - It Cannot Be Edited


Created By: Claudia Gutierrez On 01/04/2024 at 10:34 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: D'WOODSHIRE GUEST HOME
FACILITY NUMBER: 300606909

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in five out of five client files. LPA observed Needs and Services Plans to be dated from March 2015, dates have been crossed out and annually updated to new date. Needs and Services Plans have not been update and contain the same information from 2015, which poses a potential health and personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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AD stated a Needs and Services Plan would be completed for five out of five clients in care. AD will provide LPA with a copy of newly completed Needs and Services Plan via email by POC date.
Type B
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary, and in good repair at all times for the safey and well-being of clients, employees, and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above; LPA observed cobwebs in the frame of the entrance way to the hallway, a thick layer of dust covering windowsils, bathroom sink is clogged, and a patch of paint is peeling from the ceiling in the kitchen, which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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AD stated cobwebs and windowsils would be vacummed and cleaned. Drain-o was poured down the bathroom sink during vist and will be observed to ensure it is no longer clogged. A third party has been contacted to address ceiling peeling in the kitchen. AD will provide LPA with picture/video prood of corrections via email by POC date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024


LIC809 (FAS) - (06/04)
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