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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800983
Report Date: 12/06/2022
Date Signed: 12/06/2022 05:54:12 PM


Document Has Been Signed on 12/06/2022 05:54 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: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: 4DATE:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Lina AlbunoTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required - 1 Year inspection at the facility today. The LPA met with Administrator/Licensee Lina Albuna and explained the reason for the inspection.

This annual had a specific emphasis on infection control practices and procedures. The LPA 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:

KITCHEN: The kitchen and food storage areas in the kitchen and garage were observed. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen and garage. Medications are stored in a cabinet in the kitchen and were found unlocked. Cleaning supplies stored underneath the kitchen sink were also found to be unlocked.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good in condition. 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 fire extinguisher was fully charged but last serviced on 08/31/2021. The carbon monoxide detector and smoke detectors in the common rooms and bedrooms were tested and were operational. Currently, the outdoor seating for resident use is cluttered with miscellaneous items.

BEDROOMS: There are three resident bedrooms and one staff bedroom. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.



Report continued on LIC 809-C.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
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
VISIT DATE: 12/06/2022
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RESTROOMS: The facility has two common restrooms for resident use, with one restroom that has access to a resident bedroom. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. At 1:39 PM, the hot water temperature measured at 115.4 degrees F. in the hallway restroom.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE). The facility’s cleaning protocol is sufficient. Infection control signs were posted at the entry, throughout the facility, and in the restrooms. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

The following deficiencies were cited from the CA Code of Regulations. (See LIC 809-D). Exit interview and reported reviewed with the Administrator. A copy of the report was emailed.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/06/2022 05:54 PM - It Cannot Be Edited

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: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 medication cabinet was unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2022
Plan of Correction
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The medications were secured during the inspection. Plan of correction cleared.
Type A
Section Cited
CCR
87309(a)

87309 Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 cabinet under the kitchen sink which stores cleaning supplies was unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2022
Plan of Correction
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The cleaning supplies were secured during the inspection. Plan of correction cleared.

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: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 12/06/2022 05:54 PM - It Cannot Be Edited

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: 12/06/2022

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 was last serviced on 08/31/2021 which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date: 12/09/2022
Plan of Correction
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The licensee shall submit proof by 12/09/2022 that the fire extinguisher has been serviced.
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 seating for resident use is cluttered with miscellaneous items which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2022
Plan of Correction
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The licensee shall submit proof by 12/19/2022, that the outdoor seating for resident use is free of clutter and available for resident use.

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: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
LIC809 (FAS) - (06/04)
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