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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801258
Report Date: 07/07/2023
Date Signed: 07/07/2023 02:46:37 PM

Document Has Been Signed on 07/07/2023 02:46 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:MG FAMILY HOMEFACILITY NUMBER:
565801258
ADMINISTRATOR:JOSE ONGFACILITY TYPE:
735
ADDRESS:814 DOLLIE STREETTELEPHONE:
(805) 986-8908
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
07/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Maria Wilhelmina Ong MirandaTIME COMPLETED:
03:00 PM
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At 08:55 a.m. the Licensing Program Analyst (LPA) Esther Cortez 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 were four (4) caregivers and four (4) clients present. Co-Administrators Jose Ong and Maria Miranda arrived after the inspection began.

At 09:00 a.m. the LPA conducted a tour of the physical plant with Caregiver Juliet 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, two (2) living rooms and two (2) bathrooms. The home is vendored by Tri-Counties Regional Center as a level 4-I home. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 01/27/2023. At 09:15 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 9:00 a.m., the LPA observed the appliances and fixtures functional. 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.


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.
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 10:02 a.m., the water temperature in one of the restroom was measured at 105.7 degrees Fahrenheit.
Report will continue on LIC809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
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: MG FAMILY HOME
FACILITY NUMBER: 565801258
VISIT DATE: 07/07/2023
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Common Areas: These included the two living and dining areas. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in one of the living rooms, which is covered with a glass screen and blocked by furniture. The facility maintained a comfortable temperature of 69 degrees. There were no obstructions and/or tripping hazards throughout the facility.

The garage: At 09:07 a.m., the LPA observed the garage, where the washer and dryer are held, and the
emergency food and water is stored. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. The garage was not locked.

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 10:10 a.m., and 10:25 a.m., the LPA conducted two (2) staff interviews and the one (1) client present at the time did not want to be interviewed. At 2:20 p.m. the LPA interviewed one (1) staff and one (1) client. No immediate concerns voiced at this time.

Record Review: At 10:30 a.m., a review of facility files was initiated. Facility records are stored in a locked cabinet in the living area. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 07/01/2023). The LPA obtained Client Roster, Staff Roster, and Staff schedule. At 11:00 a.m., the LPA reviewed five (5) of seven (7) staff files. At 1:00 p.m., the LPA reviewed five (5) of six (6) client files. All documents reviewed appeared complete and current.

Medications: At 1:45 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.



No deficiencies cited. Exit interview conducted and copy of the report provided to Administrator Maria Miranda.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC809 (FAS) - (06/04)
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