425800643-4-2-2025-29-AS-MRAN-DFCRXW-20250402132525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800643
Report Date: 04/02/2025
Date Signed: 04/02/2025 01:25:40 PM

Document Has Been Signed on 04/02/2025 01:25 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MYDOR'S OPEN GUEST HOME IV		FACILITY NUMBER:	425800643
ADMINISTRATOR/ DIRECTOR:	JUANITO C. PASION		FACILITY TYPE:	740
ADDRESS:	819 MOSS COURT		TELEPHONE:	(805) 922-6998
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY: 4	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	04/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:09 AM
MET WITH:	Juanito Pasion		TIME VISIT/ INSPECTION COMPLETED:	01:35 PM

NARRATIVE

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Licensing Program Analyst (LPA) Rankin arrived at 11:09 am to conduct a 1-year annual visit to the facility above. LPA met Administrator Juanito Pasion and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit:

Physical Plant & Environment Safety: The facility has 5 bedrooms and 2 bathrooms, with 1 bedroom and 1 bathroom dedicated to staff. The facility is occupying 4 residents and employs 3 staff of which one is the Administrator and two are live in staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors, both were tested and were working at the time of visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe and sanitary. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in garage cabinets. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with furniture. The backyard has a locked shed to store extra furniture and items.

Operational Requirements: The facility has a current plan of operation on file. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 01/30/2026. The facility is approved for a capacity of 4 non-ambulatory of which 2 may be bedridden.

Staffing/Personnel Records & Training: The facility employes 2 staff and 1 Administrator, back-up staff are available when needed. Staff records are kept confidential. LPA reviewed 3 staff files. Files reviewed for 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. All files Continued 809-C

Kelly Burley	TELEPHONE: (805) 562-0413
Melisa Rankin	TELEPHONE: (805) 635-4718
	DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MYDOR'S OPEN GUEST HOME IV	FACILITY NUMBER: 425800643
	VISIT DATE: 04/02/2025

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were kept up to date with all requirements being met. LPA reviewed training records for Annual Training Requirements, all required annual and new hire initial training was documented.

Resident Records & Incident Reports: Four files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, and Personal Rights.. The facility does handle cash resources for two resident in care. LPA audited cash resources with ledger and cash which was balanced.

Incidental Medical & Dental: The facility has a medication cabinet in the family room that is kept locked. Facility provides or assist in providing transportation to medical and dental appointments when needed. The medications records were reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected a sampling of medication and PRN medications. PRN logs and authorization forms were present. No medications labels were altered, no expired medications, and medications were stored in original containers.

Food Service: The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. Kitchen areas are kept clean and free from litter, rodents, and insects.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts monthly disaster drills. The fire extinguishers were charged and last inspected 01/13/2025. Emergency exits and telephone numbers were posted. The facility has a sprinkler system.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have delayed egress. The facility does not currently have residents with oxygen. There are no residents on hospice or home health services at this time. The facility gates are self-closing and self-latching. The backyard is completely fenced. The facility has exiting door alarms, which were working on LPA's visit.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

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