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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801454
Report Date: 06/08/2024
Date Signed: 06/08/2024 04:41:15 PM

Document Has Been Signed on 06/08/2024 04:41 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:ARLENE'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
565801454
ADMINISTRATOR/
DIRECTOR:		CHARITO F RAMIREZFACILITY TYPE:
735
ADDRESS:4321 BROWNING DRIVETELEPHONE:
(805) 488-0322
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 5DATE:
06/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Charito F RamirezTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required 1 Year inspection at the facility today. When the LPA arrived there was two staff and five clients present. Administrator Charito Ramirez arrived shortly after the inspection began. This home serves individuals with mental illness.

Beginning at 09:56 AM, the LPA and administrator 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 observe a sufficient amount of perishable and non-perishable food in the kitchen and garage.
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 05/07/2024. 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 10:25 AM and measured at 119.3 degrees F. The backyard has covered seating for client use. There are no open bodies of water. The LPA observed the garage, where the additional food and water is stored. The garage is used to store additional supplies. The garage is unlocked.

Bedrooms: The LPA observed the four client bedrooms. At 10:10 AM the LPA observed a missing drawer in the bottom storage of a client’s bed, and at 10:12 AM the LPA observed the exit door leading to the back yard in the same room #1 (room next to the kitchen) broken. The LPA observed over the counter vitamins, Econazole Nitrate Cream and Lidocaine Ointment USP 5% in room #1. At 10:16 AM the LPA observed a bottle size hole in the wall with plumbing fixture exposed in room #2.
Report will continue on LIC 809-C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2024
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 7
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: ARLENE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565801454
VISIT DATE: 06/08/2024
NARRATIVE
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Records: Facility record review began at 11:05 AM. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 04/15/2024). The LPA reviewed the five client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All five clients were missing records in their files. Five out five clients were missing Consent Forms (LIC627 C). Client #1 was missing the following records: Personal Rights (LIC613), Identification and Emergency Information (LIC601), Functional Capability Assessment (LIC 9172). Client #2 was missing LIC613. Client #3 was missing LIC613 and LIC9172. Administrator was advised to review C3's file due to it was noted they could not leave facility unassisted. The LPA reviewed four out of four staff files but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. All four staff files were complete and current.
Medications: Medication review began at 01:45 PM. Medications are centrally stored and locked in the staff bedroom. Medications for clients are recorded on the centrally stored medications and destruction records (CSMDR). Staff are pre-pouring medication for clients for more than 24 hours in advance. LPA Observed inaccurate amounts of medications based on the date started and quantity documented on the CSMDR for C2. Med audit revealed C2 started their Topiramate 50 mg tab on 06/2 and take one tablet once a day in the morning and 2 tablets once a day at bedtime. C2’s MAR noted that they had been given their morning Topiramate 50 mg tablet this morning on the 8th, however the bubble pack still had the tablet, and in addition there were two (2) extra Topiramate morning pills and two extra Topiramate bedtime pills in the client’s medication dispenser. Med audit also revealed C2’s Lamotrigine 100 mg tabs need to be taken 1 tablet by mouth twice a day in the morning and at bedtime. C2’s MAR noted that C2 had been given their morning Lamotrigine 100 mg tablet this morning on the 8th, however the bubble pack still had the tablet, and in addition there were two (2) extra Lamotrigine morning pills and one (1) extra Lamotrigine bedtime pill in the client’s medication dispenser. Upon observation staff, administrator and LPA tried to figure out where the extra pills were from. Staff indicated that perhaps they were extra pills from previous packets, however the records from last month did not match.
Interviews: During the visit the LPA conducted two (2) client, and one (1) staff interviews. No immediate concerns voiced at this time.

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: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 06/08/2024 04:41 PM - It Cannot Be Edited


Created By: Esther Cortez On 06/08/2024 at 03:52 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: 06/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

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 as med audit revealed inaccuracies in C2 medications amounts based on the quanties which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2024
Plan of Correction
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The Administrator agrees to conduct a medication training with all staff that handles medication, and submit proof to CCL by end of day on POC due date.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 one out five rooms as over the counter vitamins, and ointments were observed in room #1 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2024
Plan of Correction
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Administrator agrees to secure all over the counter vitamins, cream, and ointments from room #1 by the end of day today and submit prood to CCL by 6/9/24. Proof can be photos or a self-certication letter.
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: 06/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/08/2024 04:41 PM - It Cannot Be Edited


Created By: Esther Cortez On 06/08/2024 at 03:52 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: 06/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

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 five out of five clients records as they all were missing documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Admiistrator agrees to conduct a file review and ensure all clients have all required documents and submit proof to CCL by 6/21/24.
Type B
Section Cited
CCR
80075(b)(5)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met:

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 five of five clients as they did not have PRN authorization forms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Administrator agrees to obtian PRN authorization forms for all clients. Adinnistrator agrees to have physician state if clients can manage over the counter medication on the form as well. Submit proof to CCL by 06/21/24
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: 06/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 06/08/2024 04:41 PM - It Cannot Be Edited


Created By: Esther Cortez On 06/08/2024 at 03:52 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: 06/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(5)
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 all medications as staff is preporing medications more than 24 hours in advanced which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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The Administrator agrees to conduct a medication audit and ensure all records are accurate, an conduct an in-service training with staff regarding regulation 80075 to CCL by 06/21/2024.
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds. (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 door in room #1 is broken, there's a missing drawer in the bed storage in room #1, and there is a whole in the wall in room #2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Administrator agrees to fix the door and drawer in room #1 and the whole in the wall in room #2 and submit proof to CCL BY 6/21/24.
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: 06/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2024


LIC809 (FAS) - (06/04)
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