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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801674
Report Date: 02/06/2025
Date Signed: 02/06/2025 02:24:23 PM

Document Has Been Signed on 02/06/2025 02:24 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:CALUYA'S RESIDENTIAL CARE HOME IIFACILITY NUMBER:
405801674
ADMINISTRATOR/
DIRECTOR:
JASON Y. CALUYAFACILITY TYPE:
740
ADDRESS:1160 15TH STREETTELEPHONE:
(805) 534-9239
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY: 4TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Adminstrator, Jason CaluyaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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At 8:30am on 02/06/2025, Licensing Program Analyst (LPA's) Jeffries and Garrett Haner-Tomasko arrived unannounced to the facility to conduct the annual facility inspection. LPA's met with the facility Administer, Jason Caluya. announced who they are and the reason for the visit.
At 9:00am Administrator and LPA's conducted a full physical inspection of the facility. This is a 3 bedroom, with dual resident occupancy, 2 resident bathrooms, bathroom 2 is an on suite resident bathroom shared by two residents. There is a living room, dinning room and kitchen. There is seating in front yard and in back yard with shade from umbrellas and awning for residents activities and visitations. LPA's noted at least two working fire extinguishers, primed and in the green. LPA tested dual smoke fire alarms and carbon monoxide detectors to be functioning as intended and located in each room of the facility. LPA's noted that the facility is a comfortable 72*(f). LPA's tested water and was in compliance with regulations standards of 105*(f) -120*(f). LPA's noted that the resident rooms had proper bedding and linin, as well as chairs and drawers for storage. LPA's noted that the bathrooms were fitted with liquid soap and paper towels and non slip mats on shower floors. LPA noted that there is at least 2 days of perishable foods and at least 7 days of non perishable foods on hand and at least 72 hours of emergency water in the garage. LPA's noted that the medications are stored and locked in the closet adjacent to the dining room competed with a 1st Aide Kit per CCLD regulations. LPA's noted that the facility is clean and free of obstacles and all exits are clean of obstacles and debit.
Administrator and LPA's conducted documentation audit of all facility staff and resident. Additionally, a cursory medication audit. LPA's noted that discontinued medication was noted and an citation was issued for custody of medication. LPA's also reviewed Emergency Disaster Plan, Infection control plan and all required postings. Administrator and LPA's conducted a full review of the care tools modules. There was one citation as a result of this full annual inspection.
Exit interview, report read, appeal rights and report provided.
Kelly BurleyTELEPHONE: (805) 562-0413
Mark JeffriesTELEPHONE: (805)562-0400
DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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Document Has Been Signed on 02/06/2025 02:24 PM - It Cannot Be Edited

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: CALUYA'S RESIDENTIAL CARE HOME II

FACILITY NUMBER: 405801674

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87465(6)(F)


This requirement is not met as evidenced by:
Deficient Practice Statement
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87465 Incidental Medical and Dental Care
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
(F) Instructions, if any, regarding control and custody of the medication.
POC Due Date: 02/20/2025
Plan of Correction
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Licensee will coordinate with Physician as to medication that has been discontinued (DC), obtain DC order. then transport DC'ed medication to pharmicy that issued for destruction, obtain a recipt from the pharmacy and provide copy of CSMR destruction.
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.
Kelly BurleyTELEPHONE: (805) 562-0413
Mark JeffriesTELEPHONE: (805)562-0400

DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025

LIC809 (FAS) - (06/04)
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