565801451-5-18-2024-29-AS-ECOZ-D5DQ9Y-20240518115907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801451
Report Date: 05/18/2024
Date Signed: 05/18/2024 11:59:59 AM

Document Has Been Signed on 05/18/2024 11:59 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LONG LIFE HOME CARE		FACILITY NUMBER:	565801451
ADMINISTRATOR/ DIRECTOR:	DELIA D. CAFUIR		FACILITY TYPE:	735
ADDRESS:	1887 CESAR CHAVEZ DRIVE		TELEPHONE:	(805) 604-0321
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY: 5		CENSUS: 5	DATE:	05/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:47 AM
MET WITH:	Delia Cafuir		TIME VISIT/ INSPECTION COMPLETED:	12:05 PM

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Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 8:47 a.m. When the LPA arrived, there were two staff and five clients present. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Delia Cafuir arrived shortly thereafter.

At 9:25 a.m. the LPA and the Administrator 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.

KITCHEN: Knives and cleaning supplies are stored inaccessible in a locked cabinet under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Kitchen was clean and sanitary.

COMMON AREAS: The living room is adjacent to the dining room. Furniture was in good condition. The facility is maintained at a comfortable temperature. There is a fireplace in the living room, which is screened and inaccessible. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was fully charged and last serviced 4/18/2024. The LPA observed required postings throughout the common space.

The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water noted. The garage and laundry room are kept locked. Cleaning supplies were kept in the laundry room. There is an emergency supply of water and non-perishable food stored in the garage.

BEDROOMS: There are three client bedrooms; one single-occupancy and two double-occupancy. LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There was a linen closet in the hallway with extra towels and linens. Report will continue on LIC809-C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024

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: LONG LIFE HOME CARE	FACILITY NUMBER: 565801451
	VISIT DATE: 05/18/2024

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RESTROOM: There is one restroom for clients. It was clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathroom was sufficiently stocked with soap and paper towels. The hot water temperature was 99.7 degrees Fahrenheit.

Interviews: The LPA initiated interviews at 9:05 a.m. The LPA conducted three (3) client interviews, and two (2) staff interviews. No immediate concerns voiced at this time.

Record Review: At 09:45 a.m., a review of facility files was initiated. Facility records are stored in a locked cabinet in the dining room. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 05/11/2024). The LPA obtained Client Roster, and Staff Roster. The LPA reviewed five (5) out of five (5) client records. Client records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

LPA reviewed five (5) out of thirteen (13) personnel records. Personnel records were reviewed for, but not limited to personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

Medications: A medication audit was initiated at 11:03 a.m. and the following was observed. 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.

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: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/18/2024 11:59 AM - It Cannot Be Edited

Created By: Esther Cortez On 05/18/2024 at 11:39 AM

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: LONG LIFE HOME CARE	FACILITY NUMBER: 565801451
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2024

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one (1) of one (1) client's restroom as the hot water measured at 99.7 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/27/2024
	Plan of Correction
1 2 3 4	The administrator agree to adjust the water temperature and ensure the water is within the required 105-120 degrees fahrenheit. The administrator shall submit proof of a five day water temperature log indicating the temperature is within the required range to CCL by 05/27/2024.

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: 05/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024

LIC809 (FAS) - (06/04)

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