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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800983
Report Date: 08/31/2021
Date Signed: 08/31/2021 04:08:10 PM

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:LINA'S GUEST HOMEFACILITY NUMBER:
565800983
ADMINISTRATOR:CELINA B. ALBUNAFACILITY TYPE:
740
ADDRESS:2221 KEPLER DRIVETELEPHONE:
(805) 487-3816
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:6CENSUS: 5DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Lina AlbunaTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required 1 Year Inspection at the facility today. When the LPA arrived, the LPA met with Administrator Lina Albuna and explained the reason for today's inspection. There are currently 5 residents and two staff which includes the Administrator present. There is currently one resident receiving hospice care, one resident receiving home health services and one resident receiving palliative care.

At 10:18 AM the LPA began a physical plant tour and reviewed infection control practices. There is one central entry point designated for universal entry screening. The facility has a sufficient supply of perishable and non-perishable food. At 10:27 AM all the smoke detectors and carbon monoxide detectors were tested and were operational. The fire extinguisher is fully charged but was last serviced on 01/27/2020. Cleaning supplies were observed to be locked and infection control practices were discussed. An inspection of the common areas, resident rooms and restrooms was conducted. Medications are locked and centrally stored in the kitchen. The hot water temperature in the common hallway bathroom measured at 109.4 degrees F. The back yard area was observed at 11:11 AM. The covered outdoor seating for resident use was cluttered with boxes and old furniture.

The licensee has submitted an exception request for Resident #1 (R1). Interviews with the administrator and record review regarding R1 were conducted during the inspection.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided via email.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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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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: LINA'S GUEST HOME
FACILITY NUMBER: 565800983
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203

87203 Fire Safety


All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

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 fire extinguisher has not been serviced since 01/27/2020 which poses a potential safety risk to persons in care.
POC Due Date: 09/03/2021
Plan of Correction
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During the inspection, staff dropped off the fire extinguisher to be serviced. The administrator shall submit proof the fire extinguisher has been serviced to CCL by 09/03/2021
Type B
Section Cited
CCR
87303(a)

87303 Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, 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 as the outdoor covered seating area for visitation is cluttered with old furniture and boxes which poses a personal rights risk to persons in care.
POC Due Date: 09/07/2021
Plan of Correction
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The administrator shall submit proof the outdoor area is free of clutter and clean and available for resident use. Proof shall be submitted by 09/07/2021.
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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2021
LIC809 (FAS) - (06/04)
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