331881257-8-22-2023-18-AS-JROO-CUXVYT-20230822165140

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881257
Report Date: 08/22/2023
Date Signed: 08/22/2023 04:51:46 PM

Document Has Been Signed on 08/22/2023 04:51 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	OSLO HOME		FACILITY NUMBER:	331881257
ADMINISTRATOR:	CLOYD, SHILOH		FACILITY TYPE:	735
ADDRESS:	3678 OSLO CT		TELEPHONE:	(619) 292-9299
CITY:	HEMET	STATE: CA	ZIP CODE:	92545
CAPACITY: 4		CENSUS: 3	DATE:	08/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Caregiver Benny Small		TIME COMPLETED:	05:00 PM

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On 8/22/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Danny Small who was informed of the purpose of visit. The facility is approved to care for four (4) ambulatory clients. During the visit, there was three (3) clients and (2) staff present.

LPA toured the facility’s interior and exterior. During the visit, LPA observed the following:

Kitchen: LPA observed kitchen area to be clean. Food is stored in a safe and healthful manner. LPA observed the facility had a 2-day supply of perishable foods and 7-day of non-perishable food items. Knives/sharp instruments are secured in a locked kitchen cabinet.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed area to be clean and furniture in good condition. LPA observed Client #1 sitting in the dining room doing crossword puzzles.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. Carbon monoxide and smoke detectors were tested and functioning properly. Cleaning solutions were secured in locked hallway closet.

Continued on LIC809-C..

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: OSLO HOME	FACILITY NUMBER: 331881257
	VISIT DATE: 08/22/2023

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Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathroom has a working toilet, wash basin, and were equipped with a grab bar in the shower. The hot water temperature measured at 110-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the clients in care.

Laundry room: LPA toured the laundry room and observed an operable washer and dryer.

Records: Staff present have a criminal record clearance on file and are associated to the facility. Staff training is up to date.

Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a kitchen cabinet. LPA reviewed physical medications for Client #1 and Client #2 as well as Medication Administration Record, no discrepancies discovered.

Yard/Outside Area: Shaded seating area is available for the clients to sit and relax. All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

During this visit, LPA was not able to enter the garage or bedroom near the entrance hallway due to both areas of the facility being locked and staff not having keys/access to them. Staff contacted Administrator Shiloh Cloyd who stated he had the keys to the garage and bedroom on his person. LPA issued a deficiency faulting the facility.

An exit interview was conducted, and a copy of this report was reviewed and provided to Caregiver Small.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/22/2023 04:51 PM - It Cannot Be Edited

Created By: Janette Romero On 08/22/2023 at 04:35 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: OSLO HOME	FACILITY NUMBER: 331881257
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80044(a)

(a) The licensing agency shall have the inspection authority specified in Health and Safety Code Sections 1562.5, 1533, 1534, 1538, and 1538.7 This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above due to the garage and bedroom being locked and LPA not having access to enter both areas, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2023
	Plan of Correction
1 2 3 4	Licensee agreed to maintain a key for garage and bedroom on the premises to allow licensing agency staff to access all areas of the facility. Proof of correction to be submitted to CCLD by close of business on POC due date.

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:

Joel Esquivel

LICENSING EVALUATOR NAME:

Janette Romero

LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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