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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801389
Report Date: 08/01/2023
Date Signed: 08/01/2023 05:00:31 PM

Document Has Been Signed on 08/01/2023 05:00 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:OPTIONS FAMILY OF SERVICES-SONATA HOMEFACILITY NUMBER:
405801389
ADMINISTRATOR:FRAN WALKERFACILITY TYPE:
735
ADDRESS:5755 VALENTINA AVENUETELEPHONE:
(805) 462-8544
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 3CENSUS: 3DATE:
08/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Tammy Peterson, Crisis Services ManagerTIME COMPLETED:
05:13 PM
NARRATIVE
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On 8/01/23 at 11:09 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced Annual/Required visit to the facility listed above. LPA met with Tammy Peterson, Crisis Services Manager (CSM), and explained the purpose of the visit.


LPA toured the facility with the CSM. There were no clients in the facility at the onset of the visit. CSM states they are at day program. Clients arrived at the facility at approximately 3:00 pm. Staff also arrived at this time. The facility is maintained in conformity with state fire marshal regulations. The smoke detector was tested and functioning properly. The facility does not have a carbon monoxide detector in the facility. Deficiency cited. Fire extinguishers (3) were located in the dining room, the end of the hallway near client bedrooms, and in the garage. Extinguishers were fully charged and last inspected on 6/6/23. There are no pools or bodies of water and no firearms or dangerous weapons stored. Between 11:38 am and 11:49 am, hot water temperatures were recorded in two resident bathrooms and the kitchen. Temperatures registered at 124 F, 138 F in the bathrooms and 132.6 F in kitchen. Deficiency cited. All toilets and hand washing facilities are maintained in a safe, sanitary, operating condition. The facility is clean, safe, sanitary and in good repair for the safety and well-being of clients, employees, and visitors. One exception is that the oven in the kitchen has food/grease spills on the bottom inside of the oven and the inside of the door. This can cause a grease fire which is a potential safety hazard. Technical violation issued. Each client is accorded safe, healthful, and comfortable accommodations, furnishings and equipment to meet his/her needs. There is a minimum 2-day supply of perishables and 7-day supply of nonperishable foods. Food is stored and prepared in a safe and healthful manner. Disinfectants, cleaning solutions and poisons are inaccessible to clients. The facility has adequate emergency supplies and first aid supplies. Facility temperature is 70 degrees F. Outdoor walkways are free from obstruction and the facility has outside covered patio areas for individuals to use. The gates on the south and north sides of the property are not closing properly. The gates do not catch the latch and are not self-closing. Licensee will fix the gates’ movement and auto-closing mechanisms, take videos, and send to LPA by 8/8/23.
Continued on 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 08/01/2023 05:00 PM - It Cannot Be Edited


Created By: Darlene Chavez On 08/01/2023 at 04:26 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OPTIONS FAMILY OF SERVICES-SONATA HOME
FACILITY NUMBER: 405801389

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that the facility does not have a carbon monoxide detector which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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Licensee will ensure a fully operating carbon monoxide detector is installed as soon as possible, but no later than 8/8/23. Licensee will test the carbon monoxide detector, take a video, and send to LPA.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 in hot water temperatures recorded in two (2) resident bathrooms and the kitchen delivered a temperature of 124 F to 138 F degrees which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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Crisis Services Manager immediately turned down the temperature on the water heater during the visit. Licensee will ensure water temperatures are adjusted to meet regulation and send a video to LPA by 8/8/23.
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:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/01/2023 05:00 PM - It Cannot Be Edited


Created By: Darlene Chavez On 08/01/2023 at 04:26 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OPTIONS FAMILY OF SERVICES-SONATA HOME
FACILITY NUMBER: 405801389

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in that two out of three clients records did not have negative tuberculosis tests whiich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2023
Plan of Correction
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Licensee will ensure that tuberculosis documentation is present in the facility and will send to LPA by end of day 8/2/23. Licensee will also sensure that no clients in the future are admitted without having a negative tuberculosis test prior to admittance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023


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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: OPTIONS FAMILY OF SERVICES-SONATA HOME
FACILITY NUMBER: 405801389
VISIT DATE: 08/01/2023
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Clients’ centrally stored medications are kept secure in a locked cabinet in the locked office and are inaccessible to clients. Medications are given as prescribed by doctors’ orders, however, five (5) of the medications/PRNs for Client #1 (C1) were not recorded on the Centrally Stored Medications List. CSM immediately recorded the medications and will ensure client medications are properly documented in the future and will conduct audits periodically. LPA reviewed (5) staff files for criminal record clearances and associations, Health screening with TB results, and current First Aid/CPR. Staff records reviewed are in-compliance. Emergency disaster drills are conducted quarterly. LPA reviewed (3) client files for current needs and services plans and signed admission agreements and personal rights. Clients #2 (C2) and #3 (C3) were accepted into the facility without written results of a negative tuberculosis test. Deficiency cited.

Exit interview conducted, deficiencies cited, technical violation issued, and the report and appeal rights given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC809 (FAS) - (06/04)
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