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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800253
Report Date: 09/09/2024
Date Signed: 09/09/2024 02:59:44 PM

Document Has Been Signed on 09/09/2024 02:59 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ASSOCIATION FOR RETARDED CITIZENS - VENTURAFACILITY NUMBER:
565800253
ADMINISTRATOR/
DIRECTOR:		MITCHEL GARCIAFACILITY TYPE:
775
ADDRESS:3340 E. LOS ANGELES AVENUETELEPHONE:
(805) 527-1358
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 90CENSUS: 32DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Micthel GarciaTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today. Upon arrival, there were sixteen (16) staff and thirty-two (32) participants. LPA met with Program Manager, Mitchel Garcia and the reason for the visit was explained. Entrance interview conducted.

The LPA along with the Programl Manager 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. The following was observed:

The participants start arriving at the day program at approximately 8:45AM and ends at approximately 3:00PM. The day program is currently staffed appropriately with the necessary staff to consumer ratios.

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The water temperature was measured in the kitchen sink at it measured 95.7 degrees Fahrenheit at 11:28AM.

BATHROOMS: There are nine (9) restrooms in the facility. Seven (7) are for participant use and two (2) are for staff only. Restrooms were clean and trash cans have lids to protect clients from cross contamination. The bathrooms were sufficiently stocked with soap and paper towels.



Report Continued on LIC 809C...
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: ASSOCIATION FOR RETARDED CITIZENS - VENTURA
FACILITY NUMBER: 565800253
VISIT DATE: 09/09/2024
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Report Continued from LIC 809...

Starting at 11:10AM, the hot water temperature was measured in participant bathrooms, and they measured between 95- and 103-degrees Fahrenheit. Staff stated water will be adjusted by maintenance department. Service request submitted at the time of the visit.

COMMON AREAS: These include five (5) activity rooms. The common areas were furnished appropriately, and all furniture was observed to be in good condition at the time of the visit. Facility maintained at a comfortable temperature. Activities are both designed for both as individuals and as a group. The LPA observed staff interacting with participants during the inspection. Equipment used for activities was in good condition at the time of the visit. Washer and dryer observed on premises locked and inaccessible to participants. No obstructions or hazards were observed inside or out.

OUTDOORS: There are two (2) outdoor areas for participant use when properly supervised. There is a shaded area with furniture appropriate for outdoor use. The exterior passageways were clean and clear of any obstructions. No bodies of water noted at the time of the visit.



RECORDS REVIEW: The LPA reviewed participant records at 11:50AM and staff records at 12:59PM.

Five (5) participant files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, needs and service plan and individualized service plan. All participant files were in order.

Five (5) staff files were reviewed for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification and yearly training. All files were complete.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

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

DATE: 09/09/2024
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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: ASSOCIATION FOR RETARDED CITIZENS - VENTURA
FACILITY NUMBER: 565800253
VISIT DATE: 09/09/2024
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Report Continued from LIC 809C...

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. There are several fire extinguishers throughout the facility; they all were fully charged and were last serviced 01/24/2024. Carbon monoxide detectors are wired and operational at the time of the visit. The last fire safety inspection was completed on 06/13/2023 and was found to be in compliance with Fire Code Regulations at the time of inspections. Yearly fire safety inspection is scheduled for the month of September. Emergency disaster drills conducted quarterly as per regulation; the last one conducted 07/31/2024.

MEDICATIONS: Medications review began at approximately 1:50PM. Medications are centrally stored and locked inside the medication room. There are currently two (2) participants with routine medications and five (5) participants with PRN medications at the time of the inspection. All medications including PRNs were labeled, stored and locked inaccessible to participants. PRNs have physicians order on file. Medications appeared to be given as prescribed at the time of the visit.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.


Exit interview conducted. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

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

DATE: 09/09/2024
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Document Has Been Signed on 09/09/2024 02:59 PM - It Cannot Be Edited


Created By: Martha Arroyo On 09/09/2024 at 02:38 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: ASSOCIATION FOR RETARDED CITIZENS - VENTURA
FACILITY NUMBER: 565800253

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures 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 LPA observation, the licensee did not comply with the section cited above as restrooms measured between 95 and 103 degrees Fahrenheit, 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 will have water temeprature adjusted and submit proof to CCL no later than POC due date.
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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


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