565801256-6-21-2023-29-AS-ECOZ-CT22B9-20230621171445

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801256
Report Date: 06/21/2023
Date Signed: 06/21/2023 05:15:37 PM

Document Has Been Signed on 06/21/2023 05:15 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EJ'S FAMILY HOME		FACILITY NUMBER:	565801256
ADMINISTRATOR:	WILHEMINA ONG		FACILITY TYPE:	735
ADDRESS:	4901 HAMILTON AVENUE		TELEPHONE:	(805) 488-3411
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 6		CENSUS: 5	DATE:	06/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Maria Wilhelmina Ong Mirandar		TIME COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 08:00 a.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 four(4) residents present. The LPA was greeted by caregiver Celia Purvis and informed them of the reason for the visit. Administrator Maria Miranda arrived shortly. At 08:20 a.m. the LPA conducted a tour of the physical plant with Administrator Maria 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 three home. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 01/27/2023. At 09:00 a.m., all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings throughout the home. Kitchen: During the facility tour at 8:40 a.m., the LPA observed the appliances and fixtures functional during the time of visit. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects are stored in locked drawers and cabinets. Food is prepared based on the menu and modified as needed for individual residents. Snacks and beverages are always available for residents. The LPA observed refrigerators to be unkempt, with stains on the fridge door. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night-stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. Report will continue on LIC809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EJ'S FAMILY HOME	FACILITY NUMBER: 565801256
	VISIT DATE: 06/21/2023

NARRATIVE

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Bathrooms: The LPA observed all bathrooms to be clean, properly supplied and had functional fixtures. Residents have sufficient amounts of supplies for personal hygiene. At 8:31 a.m., the LPA observed a disposable razor in the left drawer of the sink. Upon observation, the administrator discarded the razor. At 08:35 a.m., the water temperature in one of the restroom was measured at 113.7 degrees Fahrenheit.

Common Areas: These included the living, dining area, and office. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the living room, which is covered with a screen and blocked by furniture. The facility maintained a comfortable temperature of 71 degrees. There were no obstructions and/or tripping hazards throughout the facility.

The garage: At 08:50 a.m., the LPA observed the garage inaccessible to clients, with additional perishable and nonperishable food items. The LPA observed seven (7) boxes of hamburger helper with expiration years of 2021, and 2022, two (2) boxes of macaroni & cheese with the expiration date of 6/15/2023, and one (1) pasta bag with the expiration date of 04/15/2023. The administrator discarded all of the expired food upon observation.

Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises.

Interviews: Between 09:10 a.m., and 9:30 a.m., the LPA conducted three (3) client, and two (2) staff interviews. No immediate concerns voiced at this time.

Record Review: At 9:30 a.m., a review of facility files was initiated. Facility records are stored in a locked cabinet in the office area. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 06/01/2023). The LPA obtained Client Roster, Staff Roster, and facility Sketch. At 10:30 a.m., the LPA reviewed five (5) of five (5) Client Files. At 12:00 p.m., the LPA reviewed five (5) of five (5) staff files. All documents reviewed appeared complete and current.

Report will continue on LIC809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EJ'S FAMILY HOME	FACILITY NUMBER: 565801256
	VISIT DATE: 06/21/2023

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Medications: A medication audit for two (2) of five (5) residents was initiated at 1:45 p.m., and the following was observed. Medications are centrally stored and locked in a cabinet in the kitchen; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. During Resident #1 (R#1's) audit, the LPA observed medication missing from the bubble pack. Upon observation the Administrator stated the resident had been at the hospital during the dates the medication was missing, and the hospital had requested the medication and administered to the resident. The administrator provided the residents hospital discharge visit, and on the medication administration record each date the resident did not receive the medication from the facility was documented. Administrator also provided the medication release form issued and signed by the nurse.

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 to

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/21/2023 05:15 PM - It Cannot Be Edited

Created By: Esther Cortez On 06/21/2023 at 05:01 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: EJ'S FAMILY HOME	FACILITY NUMBER: 565801256
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as one (1) disposable razor was in the communal bathroom which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	The administrator discarder the razor upon observation, and will communicate with staff of the safety risks, and provide a self certification letter to CCL by no later than the end of day of the POC due date.

Type B

Section Cited

CCR

85076(d)(1)

Food Service

(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in ten (10) food items that were expired which poses a potential health & safety risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	Staff completed a food audit to ensure all food is of good quality, discard all expired food items during the time of visit. Administrator will send CCL a self certication letter to CCL by no later than the POC due date.

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:

Esther Cortez

LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC809 (FAS) - (06/04)

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