421703793-11-2-2023-29-AS-JOLN-CX7S5G-20231102133419

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 421703793
Report Date: 11/02/2023
Date Signed: 11/02/2023 01:35:36 PM

Document Has Been Signed on 11/02/2023 01:35 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:	JENNY'S BOARD & CARE		FACILITY NUMBER:	421703793
ADMINISTRATOR:	JENNY/QUERUBEN PEREZ 98		FACILITY TYPE:	735
ADDRESS:	1736 N. RUSSELL AVENUE		TELEPHONE:	(805) 346-8571
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY: 6		CENSUS: 6	DATE:	11/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jenny Perez, Licensee/Backup Administrator		TIME COMPLETED:	01:50 PM

NARRATIVE

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Licensing Program Analysts (LPA) Jenny Olson arrived unannounced to conduct a one year required annual. LPA met with Administrator and Licensee and explained the reason for the visit.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The facility has a sufficient supply of non-perishable and perishable food items. Cleaning supplies and disinfectants are stored in the garage, inaccessible to clients.

Common areas: Living and dining room furniture were observed to be in good condition. At 1:30 p.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced 9/14/2023.

The backyard has a covered outdoor area equipped with furniture for client use. No bodies of water noted. The washer and dryer are in the garage. The garage is not locked.

Restrooms: The client restroom was in operating condition with non-skid surfaces but needed cleaning. The bathroom was sufficiently stocked with soap and paper towels. Around 12:15 p.m., the hot water temperature measured in the client restroom at 119.8 degrees Fahrenheit.

Bedrooms: There are three (3) client rooms, which were furnished with required furniture. Beds had no fitted sheets but clients said they don't want sheets. A linen closet was located outside of the rooms, which stocked top sheets and towels.

Records: LPA reviewed client and staff records at 9:45 a.m. LPA reviewed five (5) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and needs and services plan. All files were complete. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JENNY'S BOARD & CARE	FACILITY NUMBER: 421703793
	VISIT DATE: 11/02/2023

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LPA reviewed four (4) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete.

The facility is a Mental Health Level 2 (MI2). The last disaster drill was conducted on 1/20/2016.

Medications: Medications review began at 12:30 p.m.; medications are centrally stored and locked in a file cabinet next to the kitchen. Medications are labeled and checked for expiration dates. LPA advised the Administrator to ensure that all the necessary information is properly documented on the CSMDR.

Infection Control: The facility has an infection control plan The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol needs improvement. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

LPA observed the facility floors, bathroom sink, toilet, and shower to be dirty.

LPA observed the light fixtures to be dusty.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview completed, copy of report and appeal rights were emailed and mailed to Administrator/ Licensee.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/02/2023 01:35 PM - It Cannot Be Edited

Created By: Jeannette Olson On 11/02/2023 at 01:16 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: JENNY'S BOARD & CARE	FACILITY NUMBER: 421703793
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the facility was dusty and not clean, which poses/posed a potential health and safety risk to persons in care.
	POC Due Date: 11/09/2023
	Plan of Correction
1 2 3 4	Administrator agreed to submit a plan to CCL by 11/9/23 on how they will ensure widows, floors, walls, toilets, sinks remain clean.

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 Burley

LICENSING EVALUATOR NAME:

Jeannette Olson

LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

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