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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801454
Report Date: 05/19/2023
Date Signed: 05/19/2023 06:08:17 PM

Document Has Been Signed on 05/19/2023 06:08 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 HOMEFACILITY NUMBER:
565801454
ADMINISTRATOR:CHARITO F RAMIREZFACILITY TYPE:
735
ADDRESS:4321 BROWNING DRIVETELEPHONE:
(805) 488-0322
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 4DATE:
05/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Charito RamirezTIME COMPLETED:
01:45 PM
NARRATIVE
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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 was two staff and three clients present. Administrator Charito Ramirez arrived shortly after the inspection began. This home serves individuals with mental illness.

Beginning at 10:03 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. Cleaning supplies and items that could pose a danger were secured and in a locked cabinet. The LPA did not observe a sufficient amount of perishable and non-perishable food. The LPA did not observe any fresh fruit in the home and did not observe a two day supply of perishable vegetables. The LPA also only observed only two cans of vegetables and no non-perishable fruit in the home.

Common Areas: The living room was furnished appropriately. The carbon monoxide detector and smoke alarms in the common areas and bedrooms were tested and were found to be operational. The two fire extinguishers were fully charged and last serviced on 04/10/2023. 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 hot water was tested at 10:17 AM and measured at 143.6 degrees F. The backyard has covered seating for client use. There are no open bodies of water. Infection control practices were discussed and the facility has a sufficient supply of personal protective equipment.

Bedrooms: The LPA observed the four 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: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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 8
Document Has Been Signed on 05/19/2023 06:08 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 05/19/2023 at 12:08 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: ARLENE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565801454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on observation, the licensee did not comply with the section cited above as the hot water measured at 143.6 degrees F in the common client restroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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The hot water heater was turned down during the inspection. The Administrator agrees to submit a five day water temperature log which indicates the hot water is within 105-120 degrees F to CCL by 05/26/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


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Document Has Been Signed on 05/19/2023 06:08 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 05/19/2023 at 12:08 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: ARLENE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565801454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in four out of four staff (S1, S2, S3, S4) have expired first aid training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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The Administrator agrees to submit proof all four staff have received first aid training by 06/02/2023.
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of four clients do not have record of a TB test and results which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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The Administrator agrees to submit proof C1 & C2 have had a TB test/results to CCL by 06/02/2023.
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: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/19/2023 06:08 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 05/19/2023 at 12:08 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: ARLENE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565801454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as there is an insufficient supply of perishable and non-perishable food which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2023
Plan of Correction
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The Administrator shall submit proof by 05/22/2023 that the facility has a sufficient supply of perishable and non-perishable food including fresh fruit, vegetables, and canned fruits and vegetables.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


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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: 05/19/2023
NARRATIVE
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Records: Facility record review began at 10:34 AM. The LPA reviewed the four client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. Two out of four clients (Client #1 & Client #2) were missing record of a TB test and results. The LPA reviewed four staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. All four staff (Staff #1, Staff #2, Staff #3 Staff #4) were missing current first aid training. The disaster and mass casualty plan was reviewed.

Medications: Medications review began at 11:49 AM. Medications are centrally stored and locked in the staff bedroom. Current medications for all clients are not recorded on the centrally stored medications and destruction records. Staff are also pre-pouring medication for clients for more than 24 hours in advance. First aid supplies were reviewed and complete.

Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 1 & 6, the following deficiencies was observed and cited during the visit. See LIC 809-D. Exit Interview conducted and the report was reviewed with the Administrator Charito Ramirez. Appeal Rights and a copy of this report has been issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
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Page: 7 of 8
Document Has Been Signed on 05/19/2023 06:08 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 05/19/2023 at 12:59 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: ARLENE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565801454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)(A-H
80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:(A) The name of the client for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Expiration date. (G) Number of refills. (H) Instructions, if any, regarding control and custody of the medication. This requirement is not met as evidenced by:


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Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in four out of four clients did not have their current medications recorded on the centrally stored medication records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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The Administrator shall submit proof all four clients have their current medications for May recorded on the centrally stored medication and destruction record to CCL by 05/26/2023.
Type B
Section Cited
CCR
80075(k)(5)

80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:
(5) Each client's medication shall be stored in its originally received container.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in four out of four clients had medications pre-poured and out of their original containers for more than 24 hours which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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The Administrator shall submit proof of an in-service training with staff regarding regulation 80075 to CCL by 05/26/2023.
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: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


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