<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703043
Report Date: 03/01/2022
Date Signed: 03/01/2022 03:30:24 PM


Document Has Been Signed on 03/01/2022 03:30 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:AVE'S BOARD AND CAREFACILITY NUMBER:
421703043
ADMINISTRATOR:THELMA TABLADAFACILITY TYPE:
740
ADDRESS:111 CRESCENT AVETELEPHONE:
(805) 332-3139
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:6CENSUS: 5DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Thelma TabladaTIME COMPLETED:
03:45 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
On 03/1/22 at 1:20 p.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual visit to the facility. LPA met with Administrator Thelma Tablada and explained the purpose of the visit.

At 1:34 p.m., LPA opened a closet door in the main hallway and pulled 2 spray cans identified as Gorilla Glue Adhesive and Rinso Heavy Starch Fresh Linen. Both cans were labeled to keep away from children. Administrator removed items from the closet and locked away in the staff room. At 1:47 p.m., LPA entered an unlocked shed. Within the shed was another unlocked room containing 1 Roundup spray bottle, 1 bottle with a "Glass Cleaner" handwritten on it, and 4 other cleaning spray bottles. Administrator locked the door to the shed. At 1:50 p.m., LPA entered a separate shed and found 2 Lysol toilet cleaner, 1 Lysol disinfectant aerosol, 1 Sprayway Glass Cleaner aerosol, and 1 Honest disinfecting spray bottle. LPA asked staff to move items to a locked shed. At 1:58 p.m., LPA opened a sliding closet in the office area of the facility. At hip level, LPA pulled out a basket containing staff medication. Basket contained medication bottle labeled 500 mg Acetaminophen, 100 mg Allopurinol, 400 mg Ibuprofen. There was an open container with 8 unmarked pills in the basket along with medicine bottle for Tylenol and Melatonin 5 mg. Administrator informed LPA that there is one resident diagnosed with dementia. Administrator locked medicine basket away. LPA issued citation under Title 22, Division 6 Chapter 8 Article 12. Dementia 87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
At 2:30 p.m., LPA reviewed Infection Control Module with Administrator and noted that the facility has not had staff complete fit testing for N95. All other items in the Infection Control Module were checked off as yes.

Deficiency was issued on 809D. LPA conducted exit interview, emailed a copy of the report and appeal rights to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
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 2


Document Has Been Signed on 03/01/2022 03:30 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: AVE'S BOARD AND CARE
FACILITY NUMBER: 421703043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 14 counts which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/02/2022
Plan of Correction
1
2
3
4
Administrator removed all hazardous items from current location and locked it in separate areas. Administrator will return cleaning products to cleaning to storage after usage. LPA reviewed regulations with administrator and staff. POC is completed.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2