565801259-7-14-2023-29-AS-ECOZ-CTQUB2-20230714152536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801259
Report Date: 07/14/2023
Date Signed: 07/14/2023 03:26:17 PM

Document Has Been Signed on 07/14/2023 03:26 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:	MG2 FAMILY HOME		FACILITY NUMBER:	565801259
ADMINISTRATOR:	MARIA MIRANDA		FACILITY TYPE:	735
ADDRESS:	5031 HALSEY WAY		TELEPHONE:	(805) 488-6527
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 6		CENSUS:	DATE:	07/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Maria Miranda		TIME COMPLETED:	03:30 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. the Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with Direct Care Staff Joel Tiwanak and informed them of the reason for today's visit. When the LPA arrived, there were three (3) caregivers and six (6) clients present. Administrator Maria Miranda arrived after the inspection began. At 08:30 a.m. the LPA conducted a tour of the physical plant with Direct Care Staff Joel Tiwanak 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-G home. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 06/27/2023. All smoke alarms and carbon monoxide detectors were tested during the tour. 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 and cleaning supplies are stored in a locked drawer and cabinet. 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. At 8:35 a.m. the LPA observed the dual smoke alarm and carbon detector in the staff room not working. The administrator had staff replace the dual smoke and carbon monoxide detector upon observation. Report will continue on LIC809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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: MG2 FAMILY HOME	FACILITY NUMBER: 565801259
	VISIT DATE: 07/14/2023

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 08:40 a.m., the water temperature in one of the restrooms was measured at 106.8 degrees Fahrenheit.

Common Areas: These included the two living rooms and dining area. 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 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: During the tour, the LPA observed the garage, where the washer and dryer are held, and the
emergency food and water are 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: During today’s visit the LPA conducted two (2) staff and the one (1) client interviews. No immediate concerns voiced at this time.

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

Medications: At 12:45 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.

Report will continue on LIC809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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: MG2 FAMILY HOME	FACILITY NUMBER: 565801259
	VISIT DATE: 07/14/2023

NARRATIVE

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INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff to be wearing masks. 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.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): A civil penalty of $500 was issued. 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: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/14/2023 03:26 PM - It Cannot Be Edited

Created By: Esther Cortez On 07/14/2023 at 02:42 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: MG2 FAMILY HOME	FACILITY NUMBER: 565801259
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80020(a)

80020(a) Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. Smoke detector is not operational in staff room. This is zero tolerance violation.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the dual smoke alarm and carbon monoxide detector in the staff room was not operable at the time of the visit which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/14/2023
	Plan of Correction
1 2 3 4	In accordance with the California Health and Safety Code Section 1568.0822(c), you are hereby notified that an immediate $500 civil penalty per violation, followed by $150 per day per violation will be assessed until corrected. Staff replaced the dual smoke alarm and carbon monoxide detector upon observation during the time of the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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