425800676-6-19-2023-29-AS-JOLN-CSY34P-20230619175527

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800676
Report Date: 06/19/2023
Date Signed: 06/19/2023 05:56:21 PM

Document Has Been Signed on 06/19/2023 05:56 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. III		FACILITY NUMBER:	425800676
ADMINISTRATOR:	ANTENOR PORLUCAS		FACILITY TYPE:	740
ADDRESS:	1018 N. NITA ST.		TELEPHONE:	(805) 349-0334
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	6	CENSUS: 5	DATE:	06/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Amy Antonio, Adminstrator		TIME COMPLETED:	06:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct a required annual visit. LPA was greeted by Administrator and explained the purpose of 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: Knives are stored in a locked drawer in the kitchen. Kitchen appliances were in operable and in good 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. 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.

Bedrooms: There are five (5) 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. 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. 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. 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: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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: MYDOR'S OPEN GUEST HOME, INC. III	FACILITY NUMBER: 425800676
	VISIT DATE: 06/19/2023

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MEDICATIONS: Medications review began at 4:00 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: 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.

LPA interviewed two (2) staff members and two (2) residents.

During today’s visit, the LPA obtained copies of the following: staff roster and updated facility sketch.

Around 4:30 PM LPA observed one staff to not be finger print cleared.

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

A civil penalty for $500 was assessed.

An exit interview was conducted, a copy of the report, Civil Penalty, and appeal rights were printed and emailed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/19/2023 05:56 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: MYDOR'S OPEN GUEST HOME, INC. III	FACILITY NUMBER: 425800676
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 7 staff were not fingerprint cleared, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/19/2023
	Plan of Correction
1 2 3 4	Administrator agreed to immediately ask the uncleared employee to leave and not have them return to work until they are cleared. POC cleared during the visit.

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	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

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