565801260-6-27-2023-29-AS-KLOZ-CT6TPR-20230626145445

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801260
Report Date: 06/26/2023
Date Signed: 06/27/2023 08:05:31 AM

Document Has Been Signed on 06/27/2023 08:05 AM - 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:	TON-TON FAMILY HOME		FACILITY NUMBER:	565801260
ADMINISTRATOR:	JOSE ONG		FACILITY TYPE:	735
ADDRESS:	841 BORREGO WAY		TELEPHONE:	(805) 488-8842
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 6		CENSUS: 5	DATE:	06/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:23 PM
MET WITH:	Maria Miranda		TIME COMPLETED:	03:05 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

Licensing Program Analyst (LPA) KaSandra Lopez. The LPA initially met with the caregiver and advised them of the reason for today's inspection. There are currently two caregivers and five clients living in the home. Licensee Representative Maria Miranda was contacted and arrived at the facility at during the inspection. The facility is vendored by Tri Counties Regional Center as a level 3 home.

The LPA, along with the Licensee Representative, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 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 stored. Items that could pose a danger including sharp items and cleaning supplies were secured in locked drawers. Facility has a three day supply of emergency food and water. Medications are stored in a locked drawer in the kitchen.

COMMON SPACES: In the common areas, furniture, walls, and flooring were clean and in good condition at the time of the inspection. All indoor and outdoor passages were free of obstruction. The fire extinguisher was fully charged and last serviced on 01/27/2023. At 12:39 PM, the carbon monoxide detector and smoke detectors in the common areas and bedrooms were tested and were operational. The backyard has outdoor seating for client use.

RESTROOMS: The facility has two common restroom for client use. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. At 12:33 PM, the hot water temperature was measured in the hallway common restroom and it measured at 110.3 degree F.

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

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: TON-TON FAMILY HOME	FACILITY NUMBER: 565801260
	VISIT DATE: 06/26/2023

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
26
27
28
29
30
31
32

MEDICATIONS: Medications are locked and centrally stored in the kitchen. At 12:45 PM medications for five clients were reviewed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record. The LPA inspected the first aid kit, which was complete.

RECORDS: At 1:36 PM record review for five clients and four staff was conducted. Client files reviewed were found to be complete. P&I money and records were reviewed for three clients. Cash resources were separate and intact, and not be commingled with facility funds or petty cash. Staff files reviewed were complete. Disaster drills are conducted quarterly and fire drills are conducted monthly. The facility has a 30 day supply of personal protective equipment and an emergency disaster plan.

No deficiencies were cited during today's inspection. A copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2