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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850130
Report Date: 03/20/2024
Date Signed: 03/20/2024 03:46:47 PM

Document Has Been Signed on 03/20/2024 03:46 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:GINA SCHWICHTENBERG ARF IIFACILITY NUMBER:
405850130
ADMINISTRATOR:SCHWICHTENBERG, GINAFACILITY TYPE:
735
ADDRESS:285 HEADWATERS RDTELEPHONE:
(805) 286-4008
CITY:TEMPLETONSTATE: CAZIP CODE:
93465
CAPACITY: 4CENSUS: 4DATE:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:56 AM
MET WITH: Primary Staff, Trey CorreyTIME COMPLETED:
11:37 AM
NARRATIVE
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 At 8:00am on 03/20/2024, Licensing Program Analyst (LPA) Jeffries, arrived unannounced at the facility to conduct the annual facility inspection. LPA met with Primary Staff Trey Correy (S1) announced who he was and the reason for the visit.
S1 and LPA conducted a full tour of the facility. The facility is a three bedroom two ana half bathroom, living room, kitchen and dinning area. The laundry room is locked and that is where the chemicals, medication are kept. There is a patio with shade pergola in the back yard for client to use. There are two client bedrooms that are dual occupancy and one master bedroom for the live-in staff. The clients share a full bathroom and a half bathroom and the other bathroom is the on-suite bathroom in the master bedroom designated as staff bedroom and bathroom. LPA noted that the toilet seat was off and broken in bathrooms 1 (Technical violation (TV) below, new toiled ordered). LPA noted communal washcloth in bathroom 1 (Type B violation cited below). LPA tested and noted the facility water temperature to be within regulation range of 105*-120* (f). LPA observed a first aide kit and fire extinguisher also in the laundry room. LPA noted that smoke alarms are located in each room throughout the facility and the carbon monoxide detectors in the hallway all tested and functioning as normal. LPA observed at least two days of perishable foods and more than seven days of non-perishable foods on hand at this facility. LPA observed a 30 day supply of PPE on hand at the facility. LPA noted that the facility telephone was not operational (Type B violations cited below.
LPA noted that the facility was new, clean and in good repair other than the toilet in bathroom 1.. LPA noted that all doors and exits were free of obstructions. LPA noted that that there were two Type B and one TV violations during the facility walking tour.
S1 and LPA conducted a full review of the annual control tools modules. LPA noted that there were two Type B violations as noted above and a TV as noted above, as a result of the full annual control module of the annual inspection.

Exit interview, report signed, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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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Document Has Been Signed on 03/20/2024 03:46 PM - It Cannot Be Edited


Created By: Mark Jeffries On 03/20/2024 at 11:31 AM
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: GINA SCHWICHTENBERG ARF II
FACILITY NUMBER: 405850130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)(B)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths. (B) The use of common towels and washcloths shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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:Mark Jeffries
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
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