405800923-1-3-2024-29-AS-EMIR-CZ64SS-20240103182202

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800923
Report Date: 01/03/2024
Date Signed: 01/03/2024 06:22:29 PM

Document Has Been Signed on 01/03/2024 06:22 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SOUTHBAY MAXI CARE		FACILITY NUMBER:	405800923
ADMINISTRATOR:	LITA C. LAZO		FACILITY TYPE:	740
ADDRESS:	1410 13TH STREET		TELEPHONE:	(805) 528-1725
CITY:	LOS OSOS	STATE: CA	ZIP CODE:	93402
CAPACITY:	6	CENSUS: 5	DATE:	01/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	LIta Lazo		TIME COMPLETED:	06:30 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's) Miller and De Leon arrived at 10:55 am to conduct a 1 year annual visit to the facility above. LPAs met with Administrator Lita Lazo and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectant spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). The window blinds throughout the facility need to be cleaned. All trash cans and wastebaskets have tight fitting covers. The bathroom walls need cleaning as well as dusting of cobwebs, spiders and ants. Physical Plant & Environment Safety: The kitchen cabinets and ceiling near the stove need cleaning due to grease splatter. The fire extinguishers were last charged and inspected on October 28, 2022. They are charged, but Administrator called to have extinguishers re-tagged. The facility has 6 resident bedrooms, 1 staff bedroom and 3 bathrooms currently occupying 5 residenst and employs 2 full time live in staff. and 2 Administrators. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and locked under sink and locked garage. The facility has sufficient space inside and outside for activities and visiting. The facility has an fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SOUTHBAY MAXI CARE	FACILITY NUMBER: 405800923
	VISIT DATE: 01/03/2024

NARRATIVE

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Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on August 1, 2024. The facility is approved for a capacity of 6. The fire clearance is granted for 6 Non-Ambulatory of which 1 may be bedridden in bedroom #7. Hospice is approved for 3.

Staffing: The facility currently employes 2 full time live in staff and 2 Administrators. Licensee has two facilities and employs 21 staff that can be used for back up staffing if needed, Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. One Administrator Certificate expires May 14, 2025 and one administrator is currently pending renewal.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for all subjects/topics and hours for 2023.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, LIC. 602A Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible and records are kept confidential.

Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas needed additional cleaning of grease around the stove area and cupboards. Kitchen staff are observed for personal hygiene and food sanitation practices.
Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC809 (FAS) - (06/04)

Page: 8 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SOUTHBAY MAXI CARE	FACILITY NUMBER: 405800923
	VISIT DATE: 01/03/2024

NARRATIVE

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Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents medications, no labels were altered, no medications were expired and all medications were kept in their original containers.
Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Residents with Special Health Needs: The facility does accept dementia residents in care. The facility has 2 gates on side of the home, 1 gate is in need of repair due to latch rusted and will no longer open and close and 1 gate is no longer self latching and in need of repair. One independent resident had over the counter medications and a pair of scissors in her bathroom cupboard. Administrator immediately took and locked away. Facility does not currently have anyone on oxygen . The facility currently has 1 hospice resident in care. The facility does not currently have any residents receiving Home Health services. The facility does not have delayed egress, locked doors or gates. Exit door alarms are working.

Interview conducted with Administrator - Unable to conduct interviews with residents.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC809 (FAS) - (06/04)

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