565801454-5-11-2022-29-AS-KLOZ-CEBQQP-20220511122239

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801454
Report Date: 05/11/2022
Date Signed: 05/11/2022 12:24:01 PM

Document Has Been Signed on 05/11/2022 12:24 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:	ARLENE'S RESIDENTIAL CARE HOME		FACILITY NUMBER:	565801454
ADMINISTRATOR:	CHARITO F RAMIREZ		FACILITY TYPE:	735
ADDRESS:	4321 BROWNING DRIVE		TELEPHONE:	(805) 488-0322
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 6		CENSUS: 5	DATE:	05/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	Zenaida Vitug		TIME COMPLETED:	12:30 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 conducted an unannounced Required 1 Year inspection at the facility today. When the LPA arrived there was one staff and three clients present. The LPA spoke with Administrator Charito Ramirez on the telephone at approximately 10:11 AM and informed her of the reason for today's inspection. The Administrator stated she was unable to come to the facility for the inspection but she would send staff member Zenaida Vitug in her absence. Ms. Vitug arrived at the facility at 10:32 AM. This Required - 1 Year inspection has a specific emphasis on infection control practices and procedures. Beginning at 10:17 AM, the LPA conducted a physical plant tour inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. 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. Cleaning supplies and items that could pose a danger were secured and in a locked cabinet. Common Areas: The living room was furnished appropriately. The carbon monoxide detector and smoke alarms in the common areas and bedrooms were tested at 11:10 AM and were found to be operational. The two fire extinguishers were fully charged and last serviced on 05/19/21. Ms. Vitug was reminded the fire extinguishers need their annual service. Infection control signs are posted through out the facility. The facility has one common restrooms for client use. The restroom was observed to be clean and sanitary with hand soap and paper towels. The backyard has covered seating for client use. Bedrooms: The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Medications and records are locked and stored in the staff bedroom. Report continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022

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

FACILITY NAME: ARLENE'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 565801454
	VISIT DATE: 05/11/2022

NARRATIVE

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Infection Control: During today’s visit, the LPA spoke with the care staff regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. Infection control signs are posted in the restrooms and through out the facility. The LPA observed an adequate supply of Personal Protective Equipment (PPE). The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room. The facility’s policies and procedures as it pertains to infection control are adequate.

During the inspection, it was observed that Staff #1 (S1) had criminal record clearance but was not associated to the facility. Guardian records indicate S1's criminal record clearance is currently inactive and there is no record of S1 being associated to this facility in the past. Interviews with the Administrator and staff indicate S1 has worked at the facility intermittently during the past five years. Civil penalties will be assessed today in the amount of $500 ($100 x 5 days). Civil penalties will continue accrue until the plan of correction is cleared.

The following deficiency and civil penalty was observed (See LIC 809-D.) and cited from the California Code of Regulations and/or Health and Safety code. Failure to correct the deficiencies may result in additional civil penalties. Exit interview and report reviewed with Ms Vitug. A copy of the report and appeal rights will be emailed to the Administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/11/2022 12:24 PM - It Cannot Be Edited

Created By: Kasandra Lopez On 05/11/2022 at 11:55 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: ARLENE'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 565801454
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80019(e)(2)

80019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or 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 in one staff (S1) was not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/11/2022
	Plan of Correction
1 2 3 4	Civil penalties are being assessed in the amount of $500. Civil penalties will continue to accrue until S1 is associated to the facility or proof S1 is no longer working at the facility.

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: 05/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022

LIC809 (FAS) - (06/04)

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