565801257-6-22-2023-29-AS-ECOZ-CT2UXF-20230622155817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801257
Report Date: 06/22/2023
Date Signed: 06/22/2023 03:59:35 PM

Document Has Been Signed on 06/22/2023 03:59 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EJ2 FAMILY HOME		FACILITY NUMBER:	565801257
ADMINISTRATOR:	MARIA MIRANDA		FACILITY TYPE:	735
ADDRESS:	1210 NELSON PLACE		TELEPHONE:	(805) 271-9449
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 6		CENSUS: 6	DATE:	06/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Maria Miranda		TIME COMPLETED:	04:15 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 four (4) staff and five (5) residents present. The LPA was greeted by Direct care staff Airica Abundo and informed them of the reason for the visit. Administrator Maria Miranda arrived shortly after. At 08:15 a.m., the LPA conducted a tour of the physical plant with Direct Care staff Airica Abundo 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 4-G home. The LPA observed two (2) fire extinguishers at the facility, which were fully charged and last serviced 01/27/2023. At 09:30 a.m., all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the dining room. Kitchen: During the facility tour at 08:40 a.m., the kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects and cleaning supplies 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. Bedrooms: At 08:21 a.m., the LPA observed resident bedrooms furnished with at least one night-stand, bed and sufficient lighting for each resident. Two (2) of three (3) resident rooms were observed to not have chairs for residents. The administrator stated residents did not want chairs in their rooms and have extra chairs in the home to provide upon residents’ request. 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: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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: EJ2 FAMILY HOME	FACILITY NUMBER: 565801257
	VISIT DATE: 06/22/2023

NARRATIVE

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Bathrooms: The LPA observed the resident’s bathroom to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene. At 09:01 a.m., water temperature in the resident’s restroom was measured at 109.0 degrees Fahrenheit. The LPA also observed the resident’s toilet seat had a crack on the left side. The administrator stated one of the residents had broken the toilet seat and the toilet seat was replaced during the visit.

Common Areas: These included the living, dining area and backyard. 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. The facility maintained a comfortable temperature of 71 degrees. The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. There were no obstructions and/or tripping hazards throughout the facility.

The garage: At 08:25 a.m. the LPA observed the garage, where the washer and dryer are held, and the emergency food and water is stored. The LPA observed nine (9) cans of Pork and beans with the expiration date of 12/26/2022, two (2) cans of black beans with the expiration date of 02/20/2023, one (1) can of kidney beans with the expiration date of 05/2022, and one (1) large can of tomato soup with the expiration date of 11/12/2020 in the emergency food supply. Direct Care Staff discarded the expired food items upon observation. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. The garage is not locked.
Infection Control: There was a central entry point for symptom screening and temperature checks. The LPA was appropriately screened upon entry. Facility has a sufficient supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol was sufficient. The facility's procedures as it pertains to infection control are adequate.

Record Review: At 10:15 a.m., a review of facility files was initiated. Facility records are stored in a locked cabinet in the dining room. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 05/13/2023). The LPA obtained Client Roster, Staff Roster, and facility Sketch. At 10:45 a.m., the LPA reviewed five (5) of five (5) staff Files. One of the Administrators for this facility does not have current HIV /TB training (minimum 4 hours). At 11:30 a.m., the LPA reviewed five (5) of six (6) resident files. All resident 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: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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: EJ2 FAMILY HOME	FACILITY NUMBER: 565801257
	VISIT DATE: 06/22/2023

NARRATIVE

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Medications: At 1:30 p.m. a medications review was initiated. Medications are centrally stored and locked in a cabinet in the dining room; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Interviews: During the visit the LPA conducted two (2) client, and two (2) staff interviews. The five (5) residents, and three (3) staff that were present at the beginning of the visit left to an all-day outing shortly after the LPA arrived. Prior to the end of the visit one (1) resident returned to the home. No immediate concerns voiced at this time.

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 Administrator Maria Miranda.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/22/2023 03:59 PM - It Cannot Be Edited

Created By: Esther Cortez On 06/22/2023 at 03:29 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: EJ2 FAMILY HOME	FACILITY NUMBER: 565801257
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85064(k)

Administrator Qualifications and Duties

(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as administrators file did not have an updated HIV and TB training which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/06/2023
	Plan of Correction
1 2 3 4	The Administrator has agreed to submit a copy of the HIV and TB training to CCL by no later than the end of day on the POC due date: 07/06/2023.

Type B

Section Cited

CCR

80076(a)(1)

Food Service

(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner. 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 thrirteen (13) canned food items in the emergency food suply 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 discarded all expired food items observed during the visit and has agreed to conduct a food audit of the emergency food supply. Administrator will submit proof to CCL by the end of day on the due POC 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: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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