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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800983
Report Date: 06/16/2023
Date Signed: 06/16/2023 11:05:25 AM


Document Has Been Signed on 06/16/2023 11:05 AM - 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: 3DATE:
06/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Elizabeth Galang ManguneTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Other inspection to follow up on a self reporting death report. The LPA met with Co-Administrator Elizabeth Galang Mangune and explained the reason for the inspection. On 06/10/2023, Community Care Licensing Division (CCLD) received a Death Report (LIC 624A) pertaining to Resident #1 (R1) who passed away on 06/05/2023. The report states among other diagnosis', R1 was COVID-19 positive but the Co-Administrator had not reported a COVID-19 outbreak at the facility to CCLD. On 06/12/2023 and 06/13/2023, the LPA left messages at the facility and did not receive a returned call. The emergency contact phone number on file was also not in service at this time.

During today's inspection, the LPA met with Co-Administrator Elizabeth Galang Mangune. Licensee/Administrator Celina Albuna is currently out of the country on vacation since 02/21/2023 and designated Andrie Alvarez and Elizabeth Galang Mangune to act for her in her absence. Both individuals have current administrator certificates. During the inspection, the LPA obtained current emergency contact information for the facility. The Co-Administrator stated the licensee will be out of the country for a few more months. The LPA conducted a physical plant tour of the facility and did not observe any immediate health or safety concerns and food supply was sufficient. The Co-Administrator said finances are not an issue and the licensee gave them access to the facility bank account.

The Co-Administrator states R1 became COVID-19 positive on 05/29/2023 and other residents and staff in the home subsequently became positive there afterwards. The Co-Administrator stated they did not submit an incident report to CCLD to report the positive cases, nor did they report the outbreak to Ventura County Public Health (VCPH). The LPA also reviewed the current facility personnel report summary and Co-Administrator Andrie Alvarez is not currently associated to the facility. This is an immediate zero tolerance violation. Civil penalties will be issued today and they will continue to accrue until the deficiency is corrected.
The following deficiencies were cited from the CA Code of Regulations and/or Health and Safety Code.. (See LIC 809-D). Exit interview and reported reviewed with the Co-Administrator. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
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 06/16/2023 11:05 AM - 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: 06/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2023
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review....(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by:
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The Co-Administrator understands that civil penalties will continue to accrue until proof is submitted that Andrie Alvarez is associated to the facility.
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Based on record review, the licensee failed to comply with the section cited above as the Co-Administrator/Acting Administrator Andrie Alvarez is not associated to the facility which poses an immediate health, safety, and personal rights risk to persons in care.
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Type B
06/19/2023
Section Cited
CCR87211(a)(1)

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87211 Reporting Requirements
(a) (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below....
This requirement is not met as evidenced by:
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The Co-Administrator agrees to submit written incident reports to CCLD for all positive residents in the facility by 06/19/2023. The Co-Administrator also agrees to contact VCPH today to report the outbreak.
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Based on interview and record review, the licensee failed to comply with the section cited above as the licensee failed to submit a written report when the facility had a COVID-19 outbreak which poses a potential health and safety risk to persons in care.
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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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
LIC809 (FAS) - (06/04)
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