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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800707
Report Date: 05/15/2024
Date Signed: 05/15/2024 10:58:02 AM


Document Has Been Signed on 05/15/2024 10:58 AM - 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:CLOE AND ERICA'S BOARD & CAREFACILITY NUMBER:
425800707
ADMINISTRATOR:ALAN FLOJOFACILITY TYPE:
740
ADDRESS:1027 LAUREL CT.TELEPHONE:
(805) 937-7657
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:6CENSUS: 5DATE:
05/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Alan Flojo, Owner/Licensee/AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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On 05/15/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced Case Management-Deficiencies visit. LPA arrived at the facility, met with Licensee/Administrator Alan Flojo, and announced the purpose of the visit.

On 03/07/2024, a resident fainted while at the facility, and fell causing head trauma. The resident went to the hospital overnight and was diagnosed with a sustained hematoma and concussion. The hospital cleared the resident to leave the next day; the resident returned to the facility on 03/08/2024. On 03/08/2024, the same resident wandered away/eloped from the facility through the front door. A neighbor down the street saw the resident sitting on their front lawn and called law enforcement. The resident was returned to the facility after the elopement by law enforcement on 03/08/2024. For both incidents, the licensing agency did not receive any incident reports or any telephone communication from the facility.

On 04/11/2024, LPA interviewed Staff members as well as the Licensee/Administrator about the lack of received Incident Reports to the licensing agency regarding either the incident on 03/07/2024 or 03/08/2024 occurring in the facility. The Licensee/Administrator stated that there were no Incident Reports submitted to Licensing for either the 03/07/2024 incident or the 03/08/2024 incident occurring in the facility.

The facility will be cited for deficiencies regarding Reporting Requirements to the licensing agency.

Exit interview conducted, a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
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 05/15/2024 10:58 AM - 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: CLOE AND ERICA'S BOARD & CARE
FACILITY NUMBER: 425800707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2024
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report submitted to licensing agency…within seven days...(D) Any incident that threatens welfare, safety or health of any resident
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Licensee agrees to submit Incident Reports to the Licensing Agency regarding any incident that threatens the welfare, safety, or health of any resident. LIcensing has already started to receive regular incident reports from the facility as of the Case Management-Deficiences visit by the LPA.
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This requirement was not met based on interviews and record review; licensee did not comply with section cited above when Staff Failed to notify Licenisng Department regarding a resident fall and elopement which posed a potential health and safety risk to residents in care.
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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: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
LIC809 (FAS) - (06/04)
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