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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801454
Report Date: 02/08/2022
Date Signed: 02/08/2022 12:04:49 PM

Document Has Been Signed on 02/08/2022 12:04 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: 5DATE:
02/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Charito RamirezTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case-Management - Deficiencies inspection at the facility today and met with Administrator Charito Ramirez at 9:54 AM The purpose of today's inspection was explained to the Administrator.

On 02/07/2022 at approximately 4:20 PM, LPA Angel Ascencio conducted an unannounced visit at the facility to deliver State issued COVID-19 test kits for resident visitors. During the visit, LPA Ascencio was told by a resident who answered the door that there was no staff currently present. LPA Ascencio conducted a physical plant tour and confirmed there were no staff present in the facility and the five residents were left without supervision. The residents were unable to determined how long they had been left alone without staff present. LPA Ascencio did not observe any other immediate health and safety concerns during the inspection.

Administrator Charito Ramirez was contacted by LPA Lopez on the telephone and she arrived at the facility at approximately 4:45 PM. The Administrator tried contacting the staff during the inspection with LPA Ascencio but they did not respond to the telephone calls. The Administrator confirmed with LPA Ascencio during the inspection and with LPA Lopez during a telephone call that she would remain at the facility until another staff was available and would not leave the residents unattended. LPA Ascencio concluded his inspection after the Administrator arrived.

During today's inspection, the Administrator said staff stated yesterday they went to the store and their phone was on silent when the Administrator tried contacting them. Today, staff were at an appointment which is why the Administrator is present at the facility. LPA Lopez will be issuing a citation and civil penalty due to residents being left without supervision. Exit interview and report reviewed with the Administrator. A copy of the report (LIC 809, LIC 809-D), appeal rights, and civil penalty assessment (LIC 421M) will be emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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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Document Has Been Signed on 02/08/2022 12:04 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 02/08/2022 at 10:19 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: 02/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2022
Section Cited
CCR
80065(a)

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80065 Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement is not met as evidenced by:
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The licensee/administrator shall submit a written memo of understanding of regulation 80065 and updated LIC 500 to CCL.
Civil penalties will continued to accrue until this is received.

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Based on observation on 02/07/2022 by LPA Ascencio, the licensee failed to comply with the section cited above as five residents were left without supervision which poses an immediate health, safety, and personal rights risk to residents in care,
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The licensee shall also ensure all staff receive training regarding regulation 80065 and understand staff can never leave staff unattended. Proof of training with a staff sign- in sheet shall be submitted by 2/10/2022.

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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: 02/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2022


LIC809 (FAS) - (06/04)
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