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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561703832
Report Date: 04/26/2024
Date Signed: 04/26/2024 05:59:07 PM

Document Has Been Signed on 04/26/2024 05:59 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:JOSEPHINE'S MANORFACILITY NUMBER:
561703832
ADMINISTRATOR/
DIRECTOR:		RICHARD T. CARINO IIFACILITY TYPE:
735
ADDRESS:575 SUNKISTTELEPHONE:
(805) 483-2006
CITY:PORT HUENEMESTATE: CAZIP CODE:
93041
CAPACITY: 6CENSUS: 6DATE:
04/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Charles CarinoTIME VISIT/
INSPECTION COMPLETED:
06:05 PM
NARRATIVE
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At 01:10 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 three (3) staff and no clients present. The LPA was greeted by staff Perla Laigue and informed them of the reason for the visit. Administrator Charles Carino arrived approximately at 10:20 a.m. Clients returned from day program at approximately 3:00 p.m.

At 01:22 p.m., the LPA conducted a tour of the physical plant with staff 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) resident bedrooms, one (1) staff room and two (2) bathrooms. The home is vendored by Tri-Counties Regional Center as a level 4-I home. The LPA observed a fire extinguishers at the facility, which was fully charged and last serviced 12/13/2023. All smoke alarms and carbon monoxide detectors were tested. LPA observed all required postings in the hallway of the home.
Kitchen: During the facility tour at 01:25 a.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; Sharp objects are stored in a in a locked drawer. Food is prepared based on a menu. Snacks and beverages are always available for residents.

Bedrooms: The LPA observed all resident bedrooms properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.



Bathrooms: The LPA observed all restrooms to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene. At 01:33 p.m., water temperature in one of the resident’s restrooms was measured at 109.7 degrees Fahrenheit. Report will continue on LIC809-C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
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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Document Has Been Signed on 04/26/2024 05:59 PM - It Cannot Be Edited


Created By: Esther Cortez On 04/26/2024 at 05:31 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: JOSEPHINE'S MANOR
FACILITY NUMBER: 561703832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 of 2 clients, as the quantity, fill date, and number of refills recorded on the centrally stored medication records did not match the medication label, and medication count for C2 was not accurate based on the start date recorded on the CSDMR which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2024
Plan of Correction
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Administrator has agreed to dedvelop a plan how they are going to ensure that medication is accurately documented and clients are being assisted with their medications acurrately and submit by the POC due date. Administrator has agreed to conduct medication training with staff and include training dates on their plan and will submit proof once training has been conducted.
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: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024


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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: JOSEPHINE'S MANOR
FACILITY NUMBER: 561703832
VISIT DATE: 04/26/2024
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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 of 68 degrees. There were no obstructions and/or tripping hazards throughout the facility.
The garage: The LPA observed the garage, where the washer and dryer is stored in addition to the emergency food and water. The garage is used to store additional cleaning supplies and equipment. The garage is locked.
Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture with a shaded area for clients. There are no bodies of water on the premises.
Interviews: LPA conducted two (2) staff interviews, and two (2) resident interviews. No immediate concerns voiced at this time.
Record Review: At 01:50 p.m., a review of facility files was initiated. Facility records are stored in a locked cabinet in the staff room. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 03/10/2024). The LPA obtained Client Roster, and Staff Roster. The LPA reviewed five (5) out of six (6) client files and five (5) out of eight (8) staff files. All documents reviewed appeared complete and current.

Medications: A medication audit for two (2) clients was initiated at 12:38 p.m. and the following was observed. The medications were stored in a locked cabinet in the kitchen inaccessible to the clients. Medications are labeled and checked for expiration. During Client #1 (C1's) audit, the LPA observed medications quantity, fill date and number of refills on the centrally stored medication and destruction record (CSMDR) not match the medication labels. Upon observation the administrator and staff stated the CSMDR is auto filled and provided by the pharmacy, and staff will start to review and complete if not completed accurately. During Client #2 (C2’s) audit the LPA observed medication Norgestimate/Ethinyl ESTR 0.25 MG/.35MG TABS documented with the start date of 4/1/24 on the CSMDR, and the quantity was not readable as it was covered by the medication dosage. However, the medication pack is a 28-day supply and the whole supply was full with all 28 tablets. Upon observation, staff stated that medication packet was a new packet that was going to be started and administrator stated the medication was not started on 4/1/24 and was incorrectly documented by staff.



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.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
LIC809 (FAS) - (06/04)
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