565801258-6-30-2022-29-AS-KLOZ-CFW25V-20220630170610

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801258
Report Date: 06/30/2022
Date Signed: 06/30/2022 05:07:29 PM

Document Has Been Signed on 06/30/2022 05:07 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:	MG FAMILY HOME		FACILITY NUMBER:	565801258
ADMINISTRATOR:	JOSE ONG		FACILITY TYPE:	735
ADDRESS:	814 DOLLIE STREET		TELEPHONE:	(805) 986-8908
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 6		CENSUS: 6	DATE:	06/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Jose Ong		TIME COMPLETED:	02:10 PM

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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 caregiver Rufina "Juliet" Abara initially and informed her of the reason for today's visit. When the LPA arrived there was three caregivers and six clients present. Administrator Jose Ong arrived shortly after the inspection began This home is vendored by Tri-Counties Regional Center as a level 4-I home.

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 regulations. The following was observed:

KITCHEN: The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medications are centrally stored in a locked cabinet in the kitchen.

COMMON SPACES: 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 extinguishers were fully charged and last serviced on 02/08/2022. At 1:41 PM, the carbon monoxide detector and smoke detectors in the home and bedrooms were tested and were operational. There is covered outdoor seating for client use. Cleaning supplies are stored in a locked cabinet outside. PPE is stored in the garage.

BEDROOMS: There are three client bedrooms and one staff bedroom. The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Report continued on LIC 809-C.

Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

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: MG FAMILY HOME	FACILITY NUMBER: 565801258
	VISIT DATE: 06/30/2022

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RESTROOMS: The facility has two common restrooms in the hallway for client use. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. The hot water temperature in the second hallway common restroom measured at 105 degrees F.

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.

No deficiencies cited. Exit interview and reported reviewed with the Jose Ong. A copy of the report was emailed.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

LIC809 (FAS) - (06/04)

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