405800923-12-17-2024-29-AS-MRAN-DC2TMK-20241217135117

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800923
Report Date: 12/17/2024
Date Signed: 12/17/2024 01:51:31 PM

Document Has Been Signed on 12/17/2024 01:51 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SOUTHBAY MAXI CARE		FACILITY NUMBER:	405800923
ADMINISTRATOR/ DIRECTOR:	LITA C. LAZO		FACILITY TYPE:	740
ADDRESS:	1410 13TH STREET		TELEPHONE:	(805) 528-1725
CITY:	LOS OSOS	STATE: CA	ZIP CODE:	93402
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	12/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Lita Lazo		TIME VISIT/ INSPECTION COMPLETED:	02:00 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) Rankin arrived at 09:45 am to conduct a 1 year annual visit to the facility above. LPA 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: Physical Plant & Environment Safety: The fire extinguishers were last charged and inspected on 11/4/24. The facility has 6 resident bedrooms, 1 staff bedroom and 3 bathrooms currently occupying 4 residents. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors which were tested and working at the time of visit. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety and lighting is sufficient for resident’s comfort. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and locked under sink and garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. 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 8/1/25. The facility is approved for a capacity of 6. The fire clearance is granted for 6 Non-Ambulatory of which 1 may be bedridden. 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. Continued 809-C

Kelly Burley	TELEPHONE: (805) 562-0413
Melisa Rankin	TELEPHONE: (805) 635-4718
	DATE: 12/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024

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

FACILITY NAME: SOUTHBAY MAXI CARE	FACILITY NUMBER: 405800923
	VISIT DATE: 12/17/2024

NARRATIVE

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File of two full time staff reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. One Administrator Certificate expires 5/14/25 and one administrator is currently pending renewal. Staff have annual training completed for all subjects/topics and hours for 2024.

Resident Records & Incident Reports: The facility keeps separate files on each resident. Facility does submit incident reports to the department when required. LPA reviewed 4 resident files, same residents were reviewed last annual visit, LPA looked for updated LIC. 602A Physicians report, and updated Appraisals Needs and Services Plan, all forms were updated in December of 2024, 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. 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. Facility had extra items in the freezer that will be cleaned and rotated.

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. Sampling of medication was reviewed for record keeping and count accuracy.

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, both gates need self-closing feature updated, but both self-latch and are well maintained and functional for staff and emergency personnel. Facility does not currently have anyone on oxygen. The facility currently has no hospice resident in care. The facility does not currently have any residents receiving Home Health services.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024

LIC809 (FAS) - (06/04)

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