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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801456
Report Date: 03/22/2024
Date Signed: 03/22/2024 12:40:41 PM

Document Has Been Signed on 03/22/2024 12:40 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:CEDAR HOUSEFACILITY NUMBER:
565801456
ADMINISTRATOR:LOUISA MAE ESPENAFACILITY TYPE:
735
ADDRESS:161 MARKER AVENUETELEPHONE:
(805) 484-0271
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 6DATE:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Louisa Mae EspenaTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 08:36AM. The LPA initially met with Licensee Julia Espena. LPA explained the reason for today's visit. The Administrator was contacted via telephone and arrived at 09:23AM. Entrance interview conducted.

The facility is vendored through Tri-Counties Regional Center as a level 3 home.

Beginning at 09:40AM, the LPA, along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was observed:

Individual smoke alarms and separate carbon monoxide detector were tested between 11:26AM - 11:30AM and all functioned properly. The fire extinguisher was observed to be fully charged and purchased on 07/06/2022.

COMMON SPACES: Living room, dining room, and activity room furniture was observed to be in good condition. The LPA observed the required postings upon entry and throughout the common areas.

OUTDOOR SPACE: The backyard patio contains a shaded area and is equipped with furniture for clients' use. An outdoor shed was observed to be locked. All passageways and exits were observed to be clear and free of hazards.

BEDROOMS: The LPA observed three shared client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The facility also contains a locked staff room.

RESTROOMS: 1 (one) restroom is designated for shared client use and 2 (two) are private restrooms, attached to client bedrooms. Client restrooms were observed to be clean and sanitary and in operating

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CEDAR HOUSE
FACILITY NUMBER: 565801456
VISIT DATE: 03/22/2024
NARRATIVE
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condition. Hot water was checked in the shared client restroom and measured at 115.5 degrees Fahrenheit, which is within the required range.

KITCHEN: Knives are stored in a locked drawer. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

GARAGE: LPA observed the facility garage which contained extra food, locked cleaning supplies, locked laundry supplies, emergency food and water as well as the laundry area.

CLIENT FILES/CASH RESOURCES: LPA reviewed all five (5) client files for, but not limited to: physician's report, proof of TB test, Admission Agreement, and cash resources. 2 (two) of 5 (five) client files reviewed contained record of cash resources that did not match the cash amounts for those clients. Administrator indicated that clients had taken their cash for lunches and had not returned the receipts yet.

STAFF FILES: LPA reviewed five (5) staff files for, but not limited to: fingerprint background clearance, health screening, TB test, and training records. Administrator certificate expired on 11/05/2023 and Administrator indicated the packet for renewal was not sent until after the expiration date, then was returned and was not re-submitted for review until 03/09/2024.

MEDICATION REVIEW: Beginning at 11:36AM, LPA reviewed medications for 2 (two) clients. All medications reviewed were documented and stored in compliance with regulation.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted monthly, with the last drill documented on 02/18/2024. Emergency disaster plan was observed to be complete and updated annually as required.

INTERVIEWS: Throughout the duration of today's visit, all clients and staff were out of the facility, therefore no interviews were conducted.

The following deficiencies were observed and cited from the California Code of Regulations, Title 22 and/or 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: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/22/2024 12:40 PM - It Cannot Be Edited


Created By: Kelly Dulek On 03/22/2024 at 12:01 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: CEDAR HOUSE
FACILITY NUMBER: 565801456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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 the facility fire extinguisher was observed to be fully charged but was not checked annually and was purchased on 07/06/2022, which poses a potential safety risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Administrator agreed to either purchase a new fire extinguisher or to have annual maintenance performed on the current one and provide proof to CCL by POC due date.
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as the Administrator's certificate expired on 11/05/2023, but an application for renewal was not submitted timely, with the first attempt in February 2024 and was not fully received for processing until 03/09/2024 which poses/posed a potential personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Administrator agreed to come up with a plan for complaince to involve CCL and Tri-Counties Regional Center and communicate the plan in writing to CCL by POC due date.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/22/2024 12:40 PM - It Cannot Be Edited


Created By: Kelly Dulek On 03/22/2024 at 12:01 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: CEDAR HOUSE
FACILITY NUMBER: 565801456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(14)
Client Records
(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as 2 clients (Client #1 - C1 and Client #2 - C2) out of 5 total client files reviewed had cash resources on hand which did not match the amount shown on their cash ledger which poses a potential personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Administrator agreed to obtain all receipts from C1 and C2, update the records for both clients, and send proof of reconciled cash resources for both clients to CCL by POC due date.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
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