565801357-3-21-2024-29-AS-ECOZ-D3KRCT-20240321125452

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801357
Report Date: 03/21/2024
Date Signed: 03/21/2024 12:55:56 PM

Document Has Been Signed on 03/21/2024 12:55 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:	EJ-3 FAMILY HOME		FACILITY NUMBER:	565801357
ADMINISTRATOR:	WILHELMINA ONG		FACILITY TYPE:	735
ADDRESS:	721 YALE PLACE		TELEPHONE:	(805) 986-5429
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 4		CENSUS: 4	DATE:	03/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Joemar Ong		TIME COMPLETED:	01:00 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 09:00 a.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA wet with Co-administrator Joemar Ong and informed them of the reason for the visit. At 09:15 a.m., the LPA conducted a tour of the physical plant with the Administrator Joemar 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 double-story residence that consists of two (2) resident bedrooms, and one (1) bathroom on the first floor. The second floor is solely for staff and inaccessible to residents in care. The home is vendored by Tri-Counties Regional Center as a level 4-I home. The LPA observed fire extinguishers at the facility, which were fully charged and last serviced 01/18/2024. All smoke alarms and carbon monoxide detectors were tested and functioned properly. LPA observed all required postings in the facility. Kitchen: During the facility tour the kitchen appeared clean and 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 a locked box and cleaning supplies are stored in a locked cabinet under the sink. Food is prepared based on the client’s dietary needs. Snacks and beverages are always available for residents. Bedrooms: The LPA observed all resident bedrooms properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: The LPA observed the residents’ bathroom to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene. At 09:21 a.m., water temperature in the resident’s restroom was measured at 112.2 degrees Fahrenheit. REPORT WILL CONTINUE ON LIC809-C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

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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Document Has Been Signed on 03/21/2024 12:55 PM - It Cannot Be Edited

Created By: Esther Cortez On 03/21/2024 at 12:10 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: EJ-3 FAMILY HOME	FACILITY NUMBER: 565801357
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80065(f)

Personnel Requirements

(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as staff #1 did not have any documentation for any trainings received by the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/29/2024
	Plan of Correction
1 2 3 4	Licensee will conduct all required training with Staff 1 and submit the training records to CCL on or before 03/29/2024.

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:

Kasandra Lopez

LICENSING EVALUATOR NAME:

Esther Cortez

LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: EJ-3 FAMILY HOME	FACILITY NUMBER: 565801357
	VISIT DATE: 03/21/2024

NARRATIVE

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Common Areas: These included the 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 the second living room, which is covered with a screen. The facility maintained a comfortable temperature of 69 degrees. There were no obstructions and/or tripping hazards throughout the facility.

The garage: The LPA observed the garage, where the emergency food is stored and the washer and dryer are held. The garage is used to store additional supplies. The garage is unlocked.

Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water on the premises.

Interviews: The LPA conducted one (1) resident and one (1) staff interview, staff and clients left the facility during the visit. No immediate concerns voiced at this time.

Record Review: At 09:40 a.m., a review of facility files was initiated. Facility records are stored in a locked cabinet in the second living room. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 03/18/2024). The LPA obtained Client Roster, Staff Roster and facility sketch. The LPA reviewed four (4) out of four (4) client files. All documents reviewed appeared complete and current. The LPA observed five (5) out of six (6) staff files and the following was observed: Staff #1 (S1) did not have any training records on file. Otherwise, all other documents reviewed appeared complete and current.

Medications: Medications review began at 11:38 a.m.; medications are centrally stored and locked in a cabinet in a hallway; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.

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.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC809 (FAS) - (06/04)

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