561703412-8-25-2023-29-AS-TCAA-CV2VT2-20230825164224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 561703412
Report Date: 08/25/2023
Date Signed: 08/25/2023 04:43:15 PM

Document Has Been Signed on 08/25/2023 04:43 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:	CUDAL BOARD AND CARE HOMES		FACILITY NUMBER:	561703412
ADMINISTRATOR:	PERFECTO P. CUDAL		FACILITY TYPE:	735
ADDRESS:	1930 ONTARIO STREET		TELEPHONE:	(805) 985-5646
CITY:	OXNARD	STATE: CA	ZIP CODE:	93035
CAPACITY: 6		CENSUS: 5	DATE:	08/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:22 PM
MET WITH:	Perfecto Cudal		TIME COMPLETED:	03:45 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) Teresa Camara conducted an unannounced required annual visit. At 1:22 p.m., the LPA met with the Licensee, Perfecto P. Cudal and explained the reason for the visit. At 1:24 p.m. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. The fire extinguisher was last serviced on 8/22/2023. The carbon monoxide and smoke detectors were tested and appeared to function properly. COMMON SPACES: All indoor and outdoor passages were free of obstruction. At the time of the visit, living room and dining room furniture was observed to be in good condition. The last recorded emergency drill was an earthquake drill 6/5/2022. BEDROOMS: There are a total of five (5) bedrooms, three (3) for client use and two (2) for staff use. The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Medications are centrally stored and in a locked cabinet in one of the staff rooms. RESTROOMS: Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. At 1:35 p.m. the hot water temperature tested at 140.3 degrees Fahrenheit which is higher than the temperature allowed by regulations (105F-120F). (continued on 809-C; page 2)

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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 3

Document Has Been Signed on 08/25/2023 04:43 PM - It Cannot Be Edited

Created By: Teresa Camara On 08/25/2023 at 03:08 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: CUDAL BOARD AND CARE HOMES	FACILITY NUMBER: 561703412
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). 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 as the hot water temperature measured in the hall bathroom was 140.3*F, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/01/2023
	Plan of Correction
1 2 3 4	Licensee will lower the hot water temperature to be within the range of 105F - 120F. Licensee will measure the temperature three days in a row after lowering the hot water temperature and report those temperatures to CCL on or before 9/1/2023.

Type B

Section Cited

HSC

1565(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. 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 as the last emergency drill was conducted in 2022, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/01/2023
	Plan of Correction
1 2 3 4	Licensee will conduct an emergency drill and provide evidence of the drill to CCL on or before 9/1/2023. In addition, the licensee will provide a written plan for when they will conduct their quarterly emergency drill meetings.

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:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Teresa Camara

LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: CUDAL BOARD AND CARE HOMES	FACILITY NUMBER: 561703412
	VISIT DATE: 08/25/2023

NARRATIVE

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(continued from 9099; page 1)

KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

OUTDOOR SPACE: LPA observed the back patio which has a covered outdoor area for client use. There is a gate designated for an emergency exit.

GARAGE: The garage is attached to the house. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the garage. The laundry units are located inside the garage.

INFECTION CONTROL: The LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s policies and procedures as it pertains to infection control are adequate.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D; page 3):

Exit interview conducted. Today's reports, and appeal rights were reviewed and issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC809 (FAS) - (06/04)

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