565801393-8-4-2023-29-AS-KLOZ-CUDUGL-20230804153431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801393
Report Date: 08/04/2023
Date Signed: 08/04/2023 04:35:51 PM

Document Has Been Signed on 08/04/2023 04:35 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GONZALES FAMILY HOME		FACILITY NUMBER:	565801393
ADMINISTRATOR:	VENIE G. GONZALES		FACILITY TYPE:	735
ADDRESS:	4450 BROWNING DRIVE		TELEPHONE:	(805) 488-2315
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 6		CENSUS: 6	DATE:	08/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:03 PM
MET WITH:	Leonardo Tugade		TIME COMPLETED:	03:45 PM

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required 1 Year inspection at the facility today. When the LPA arrived there were four staff and six clients present. The LPA explained the reason for the inspection. The Administrator Venie Gonzales was contacted during the inspection but was unable to come to the facility. The Administrator gave permission for staff to sign the report. This home is vendored by Tri-Counties Regional Center as a level 4-I home.

The LPA 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. Knives and sharp items that could pose a danger are stored in a cabinet in the kitchen. During the visit at 1:07 PM, the LPA observed the cabinet to be unlocked. Medications are stored in a locked cabinet in the dining room area.

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 07/23/2023. At 1:26 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 one private and one common restroom for client use. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. At 1:14 PM, the hot water temperature was measured in the hallway common restroom and it measured at 109.5 degree F.

Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

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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Document Has Been Signed on 08/04/2023 04:35 PM - It Cannot Be Edited

Created By: Kasandra Lopez On 08/04/2023 at 02:51 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: GONZALES FAMILY HOME	FACILITY NUMBER: 565801393
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in as the cabinet that stores knives and sharp items was unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/11/2023
	Plan of Correction
1 2 3 4	The cabinet was locked during the inspection. The Administrator shall submit proof staff have received training regarding securing items that could pose a danger. Training shall be submitted to CCL by 08/11/2023.

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:

Kasandra Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GONZALES FAMILY HOME	FACILITY NUMBER: 565801393
	VISIT DATE: 08/04/2023

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BEDROOMS: There are four client bedrooms. The LPA observed the client bedrooms to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There is no staff room, therefore the home has 24 hour awake staff.

MEDICATIONS: Medications are locked and centrally stored in a locked cabinet in the dining room area. At 1:29 PM medications for three 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 1:39 PM the LPA reviewed P&I money and records with staff. Cash resources for all six resident whom they store funds for, were separate and not be commingled with facility funds or petty cash. Six client files reviewed were found to be complete. Four staff files were reviewed and also found to be complete. Disaster drills are conducted monthly. The facility has a 30 day supply of personal protective equipment and an emergency disaster plan.

INTERVIEWS: Interviews with two staff and one client was conducted. No issues or concerns observed. The LPA was unable to conduct interviews with any other clients do their cognitive abilities.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC809 (FAS) - (06/04)

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