306005941-4-17-2024-22-AS-JHAY-D4ET9W-20240417143237

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005941
Report Date: 04/17/2024
Date Signed: 04/17/2024 02:32:51 PM

Document Has Been Signed on 04/17/2024 02:32 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	HORWITZ FAMILY HOUSE		FACILITY NUMBER:	306005941
ADMINISTRATOR/ DIRECTOR:	MCDONALD, LISA		FACILITY TYPE:	735
ADDRESS:	1621 PORTOLA AVENUE		TELEPHONE:	(818) 782-2211
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY: 6		CENSUS: 1	DATE:	04/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:05 AM
MET WITH:	Ivy Contreras - Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

NARRATIVE

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Licensing Program Analysts (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA Haley was greeted and granted entry by staff and explained the reason for the visit. Staff contacted Administrator Ivy Contreras who arrived a short time later and was present for the remainder of the of the visit.

During the inspection, LPA Haley observed all client bedrooms and bathrooms. All client bedrooms had the necessary elements and were in compliance with regulation guidelines. Client bathrooms were clean and organized. Hot water temperatures were measured in the range of 110.3 degrees Fahrenheit and 112.2 degrees Fahrenheit. Unsecured hazardous cleaning items were observed in one of the client bathrooms in the cabinet under the sink and were properly secured upon discovery. Client medications, a first aid kit, and Client P&I funds are locked in a closet near the entrance of the facility.

In the kitchen, knives and sharp objects are kept locked in a drawer. A pair of scissors were observed on the kitchen counter top near the phone and were properly secured upon discovery. A perishable food supply that meets regulation requirements was observed in the refrigerator. A non-perishable food supply that meets regulation requirements was observed in the cabinets. There is a washer and dryer in the laundry room right outside the garage with a supply of emergency food buckets.

The garage was organized and free of clutter. A locked cabinet with hazardous cleaning items, COVID PPE supplies, and hygiene items was observed. There was a second locked cabinet with an addition supply of non-perishable food items. A refrigerator for one of the client’s personal food items was observed in the garage. In the middle of the garage, exercise equipment (treadmill, exercise bike, etc.) was observed. Office supplies and items for activities are stored in the garage as well.

The backyard was clean, organized, and walkways were free of obstruction. A shaded patio area with a table and chairs was observed.

Continued on LIC809C

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HORWITZ FAMILY HOUSE	FACILITY NUMBER: 306005941
	VISIT DATE: 04/17/2024

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There's a locked shed in the backyard used to store miscellaneous facility items, an emergency supply of water, and some paint. Both side exit gate are self-closing and self-latching.

Smoke detectors, and the carbon monoxide detector tested operational. A fully charged fire extinguisher was observed mounted on the wall in the dining room, and one mounted on the wall on the second level of the facility near a client bedroom.

An emergency evacuation drill was conducted March 11, 2024 and are conducted monthly for staff on each shift.

Deficiencies will be cited as a result of today’s visit.

An exit interview conducted, and a copy of this report and appeal rights were provided to Administrator Contreras.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/17/2024 02:32 PM - It Cannot Be Edited

Created By: Jerome Haley On 04/17/2024 at 01:56 PM

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: HORWITZ FAMILY HOUSE	FACILITY NUMBER: 306005941
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(g)

Disinfectants, cleaning solutions, poisions, cleaning solutions, and other items that could pose a danger if left readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. During the inspection LPA Haley and Administrator Contreras observed hazardous cleaning items unsecured in a client's bathroom under the sink and two pairs of scissors unsecured during the inspection. The first pair of scissors was observed in the kitchen and the second pair of scissors was observed in a clients bedroom which posed a potential safety risk to persons in care.
	POC Due Date: 04/24/2024
	Plan of Correction
1 2 3 4	Administrator Contreras agrees to read and review regulation section 80087 Buildings and Grounds and send a signed statement of acknowledgement and understanding upon completion. Administrator Contreras will schedule an in-service training for all staff and email the sign-in sheet for all staff in attendance and a detailed breakdown of the topics covered in the in-service training. POC is due April 24, 2024 at 1:00PM.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Luz Adams

LICENSING EVALUATOR NAME:

Jerome Haley

LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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