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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561703412
Report Date: 09/12/2024
Date Signed: 09/12/2024 04:03:38 PM

Document Has Been Signed on 09/12/2024 04:03 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:CUDAL BOARD AND CARE HOMESFACILITY NUMBER:
561703412
ADMINISTRATOR/
DIRECTOR:		PERFECTO P. CUDALFACILITY TYPE:
735
ADDRESS:1930 ONTARIO STREETTELEPHONE:
(805) 985-5646
CITY:OXNARDSTATE: CAZIP CODE:
93035
CAPACITY: 6CENSUS: 5DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Cudal P PerfectoTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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At 12:15 p.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. When the LPA arrived, there were two (2) staff and three (3) clients present. The LPA was greeted by Licensee Cudal Perfecto and informed them of the reason for the visit.

At 12:30 p.m., the LPA conducted a tour of the physical plant with the Administrator to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of three (3) client bedrooms, two (2) staff bedrooms and two (2) bathrooms. The LPA observed fire extinguishers at the facility, which were fully charged and last serviced 08/27/2024. At 12:48 p.m., all smoke alarms and carbon monoxide detectors were tested and operable.

Kitchen: During the facility tour at 12:33 p.m., the kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Knifes and sharp objects are stored in a locked drawer in the kitchen and cleaning supplies are stored in a locked cabinet in the garage next to the kitchen. At 12:33 p.m. the LPA observed ants in the pantry of the kitchen. At 12:43 p.m. the LPA observed prescribed medication in an unlocked kitchen cabinet accessible to clients in care.

The garage: The LPA observed the garage that is attached to the kitchen. The garage is where the refrigerator and additional food is stored. The garage is also where the washer and dryer are held. The garage is left unlocked during the day. At 12:35 p.m. the LPA observed chicken that was not appropriately covered in the refrigerator. At 12:36 p.m. the LPA observed unlocked medication in the refrigerator accessible to clients in care.



Report will continue in LIC809-C. (2nd Page).
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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 7
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: CUDAL BOARD AND CARE HOMES
FACILITY NUMBER: 561703412
VISIT DATE: 09/12/2024
NARRATIVE
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Bedrooms: The LPA observed all client bedrooms. At 12:53 p.m. the LPA observed a drawer missing from the nigh stand in client bedroom #1. At 12:58 p.m. the LPA observed spider webs in the ceiling and walls in client bedroom #2, a heavily soiled pillow in a resident’s bed, and spots and dirt on the floor. At 1:00 p.m. the LPA observed spider webs on the ceiling and walls of client bedroom #3. Upon on observation, the Licensee replaced the soiled pillow in the client bedroom #2.

Bathrooms: The LPA observed the private client’s bathroom and the outside bathroom to be properly supplied. Residents have sufficient supplies for personal hygiene. At 12:55 p.m., water temperature in the outside restroom was measured at 122.9 degrees Fahrenheit. At 1:02 p.m., water temperature in the private bathroom was measured at 120.7 degrees Fahrenheit, and the LPA observed the private bathroom with stains, toilet paper and dirt on the floor, and stained toilet cover.

Common Areas: These included the living, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature. There were no obstructions and/or tripping hazards throughout the facility.
Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture with a shaded area for clients in the backyard. There are no bodies of water on the premises.

Interviews: LPA conducted two (2) client and one (1) staff interviews. No immediate concerns voiced at this time.

Record Review: At 1:40 p.m., a review of facility files was initiated. Facility records are stored in the locked staff room. The LPA observed documentation of Infection Control, and last Disaster drill (conducted on 06/12/2024). The LPA obtained Client Roster, and Staff Roster. The LPA reviewed five (5) out of five (5) client files. The LPA observed four (4) out of four (4) staff files. All documents reviewed appeared complete and current. The LPA did not observe an Emergency and Disaster Plan on file.
Medications: Medications review began at 03:10 p.m.; medications are centrally stored and stored in a locked staff room; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Licensee.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7
Document Has Been Signed on 09/12/2024 04:03 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/12/2024 at 03:28 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: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(h)
Building and Grounds
(h) Medicines shall be stored as specified in Section 80075(m) and (n) and separately from other items specified in Section 80087(g) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above in five out of five medications observed accessible to the clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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2
3
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Upon observation, the Licensee locked the medications that were observed in the kitchen and agrees to place the medications in the refrigerator inaccessible to the clients in care and submit proof to CCL by 09/13/24.
Type A
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
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Based on observation, the licensee did not comply with the section cited above in two out of two bathroom sinks where the hot water measured above 120 fegress F which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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4
The licensee agrees to adjust the water temperature and submit proof to CCL by 09/13/24.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 09/12/2024 04:03 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/12/2024 at 03:28 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: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in three out of three client bedrooms, and one client bathroom that were observed with a misisg drawer, or spider webs on the walls and ceilings, or dirty floots which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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Licensee agrees to have the clients rooms and client's private bathroom cleaned and nightstand drawer fixed and submit proof to CCL by 09/16/24.
Type B
Section Cited
CCR
80076(a)(18)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (18) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the LPA observed uncovered seasoned raw chicken in the refrigerator which posed a potential health and safety risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
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POC has been met, upon observation the Licensee covered the chicken.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 09/12/2024 04:03 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/12/2024 at 03:28 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: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on review, the licensee did not comply with the section cited above in as they need have an emergency and disaster plan on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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Licensee agreed to submit an emergency and disaster plan to CCL by 09/16/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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