425800674-5-15-2023-29-AS-JOLN-CRV2M9-20230515173047

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800674
Report Date: 05/15/2023
Date Signed: 05/15/2023 05:31:17 PM

Document Has Been Signed on 05/15/2023 05:31 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:	MYDOR'S OPEN GUEST HOME, INC. I		FACILITY NUMBER:	425800674
ADMINISTRATOR:	JUANITO C. PASION		FACILITY TYPE:	740
ADDRESS:	742 E. MC ELHANY AVE.		TELEPHONE:	(805) 922-0412
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	6	CENSUS: 6	DATE:	05/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Antenor Porlucas and Juantio Pasion, Administrator		TIME COMPLETED:	05:45 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

Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct a required annual visit at 10:45 a.m. When LPA arrived, there were three staff and six residents present. LPA was greeted by Administrator Antenor Porlucas and informed them of the reason for the visit. Juanito Pasion and Amy Antonio also were present.

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: Knives are stored in a locked drawer in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

Common areas: Living and dining room furniture were observed to be in good condition. There is a fireplace in the family room, which is screened and inaccessible. At 2:30 p.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced 2/13/2023.

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 locked.

Restrooms: The two resident restrooms were clean and sanitary and in operating condition with non-skid mats. The bathrooms were sufficiently stocked with soap and paper towels. Around 2:40 p.m., the hot water temperature measured in the kitchen at 112.8 degrees Fahrenheit.

Bedrooms: There are four (4) resident rooms, which were furnished with appropriate linens. A linen closet was located outside of the rooms, which stocked extra linens and towels.

Records: LPA reviewed resident and staff records at 10:50 a.m. LPA reviewed five (5) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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 10

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: MYDOR'S OPEN GUEST HOME, INC. I	FACILITY NUMBER: 425800674
	VISIT DATE: 05/15/2023

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
26
27
28
29
30
31
32

Residents don't have a needs a services plan, they have a Individual Services Plan (ISP). LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete.

MEDICATIONS: Medications review began at 12:30 p.m. The medications are centrally stored and locked in a cabinet in the office. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of COVID. 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 is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

At 4:30 p.m., LPA interviewed two (2) staff members and two (2) residents.

During today’s visit, the LPA obtained copies of the following: staff roster, resident roster and current liability insurance.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 10