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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801258
Report Date: 07/03/2024
Date Signed: 07/03/2024 04:48:49 PM

Document Has Been Signed on 07/03/2024 04:48 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MG FAMILY HOMEFACILITY NUMBER:
565801258
ADMINISTRATOR/
DIRECTOR:		JOSE ONGFACILITY TYPE:
735
ADDRESS:814 DOLLIE STREETTELEPHONE:
(805) 986-8908
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Mari MirandaTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
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At 01:30 p.m. the Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with caregiver Antipaz Pacheco initially and informed them of the reason for today's visit. When the LPA arrived there were four (4) staff and four (4) clients present. Co-Administrators Maria Miranda arrived shortly after.

At 01:40 p.m. the LPA conducted a tour of the physical plant with the Administrator 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) client 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 06/18/2024. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings throughout the home. One (1) client arrived during the visit.

KITCHEN: The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. Cleaning supplies and items that could pose a danger were secured and in a locked cabinet. At 2:17 p.m. the LPA did not observe a supply of staple nonperishable foods for a minimum of one week. The LPA only observed approximately 25 cans combined of the following: tomato soup, green beans, mushroom soup, enchilada sauce, pasta sauce, and Alfredo sauce. Upon observation, administrator had staff bring canned goods and fruits and vegatables.



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 will continue on LIC809-C
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MG FAMILY HOME
FACILITY NUMBER: 565801258
VISIT DATE: 07/03/2024
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Bathrooms: The LPA observed all bathrooms to be clean, properly supplied and had functional fixtures. Clients have sufficient amounts of supplies for personal hygiene. At 1:58 p.m., the water temperature in one of the restroom was measured at 101 degrees Fahrenheit. Upon observation staff adjusted the water temperature. At 3:15 p.m. the water temperature in the same restroom was measured at 104.7 degrees Fahrenheit.
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 74 degrees. There were no obstructions and/or tripping hazards throughout the facility. The LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water on the premises.
The garage: 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.

Interviews: The LPA conducted two (2) staff and two (2) client interviews. No immediate concerns voiced at this time.

Record Review: At 2:30 p.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 07/01/2024). The LPA reviewed five (5) of seven (7) staff files and (5) of six (6) client files including P&I money and records. Cash resources were separate and intact, and not be commingled with facility funds or petty cash. All documents reviewed appeared complete and current.

Medications: At 3:40 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.

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 were provided to the administrator.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2024 04:48 PM - It Cannot Be Edited


Created By: Esther Cortez On 07/03/2024 at 04:15 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: MG FAMILY HOME
FACILITY NUMBER: 565801258

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one of two bathrooms as the water temprature in one of the bathrooms measured below 105 degrees Farenheit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Administrator agreed to adjust the water temperature and submit a 5 day water log of temperature in the restroom within the required water temperature of 105-120 degrees F and submit by 07/12/2024.
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
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Based on observation, the licensee did not comply with the section cited above as the LPA observed an insufficient supply of non-perishable food which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2024
Plan of Correction
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The Administrator shall submit proof by 07/05/2024 that the facility has a sufficient supply of perishable and non-perishable food including but not limited to vegetables, canned fruits and vegetables, rice, pastas, eggs, milk.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024


LIC809 (FAS) - (06/04)
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