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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801259
Report Date: 07/09/2024
Date Signed: 07/09/2024 06:23:48 PM

Document Has Been Signed on 07/09/2024 06:23 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:MG2 FAMILY HOMEFACILITY NUMBER:
565801259
ADMINISTRATOR/
DIRECTOR:		MARIA MIRANDAFACILITY TYPE:
735
ADDRESS:5031 HALSEY WAYTELEPHONE:
(805) 488-6527
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:40 PM
MET WITH:Maria MirandaTIME VISIT/
INSPECTION COMPLETED:
06:25 PM
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At 03:40 p.m. Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with Direct Care Staff Rose Cocjin 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 03:48 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) 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 06/18/2024. All smoke alarms and carbon monoxide detectors were tested during the tour and functioned properly. The LPA observed all required postings throughout the home.

KITCHEN: 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. .

Report will continue on LIC809-C
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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: MG2 FAMILY HOME
FACILITY NUMBER: 565801259
VISIT DATE: 07/09/2024
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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 4:00 p.m., the water temperature in one of the restrooms was measured at 103.1 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. 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 two (2) client interviews. No immediate concerns voiced at this time.

Record Review: At 04:11 p.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 06/02/2024). The LPA reviewed five (5) of six (6) client files and five (5) of seven (7) staff files. All documents reviewed appeared complete and current. P&I money and records were reviewed for all six (6) clients. Cash resources were separate and intact, and not be commingled with facility funds or petty cash.

Medications: At 5:24 p.m. a medications review for two (2) clients 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 provided to administrator Maria Miranda.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/09/2024 06:23 PM - It Cannot Be Edited


Created By: Esther Cortez On 07/09/2024 at 05:50 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: 07/09/2024

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 as water temperature in one of the restrooms measured at 103.1 F which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Administrator agrees to adjust the water temperature and submit a five (5) day temperature log to CCL by 07/19/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


LIC809 (FAS) - (06/04)
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