565801457-10-30-2024-29-AS-TBYE-DAJSHD-20241030135321

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801457
Report Date: 10/30/2024
Date Signed: 10/30/2024 01:54:18 PM

Document Has Been Signed on 10/30/2024 01:54 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:	CARING HOME		FACILITY NUMBER:	565801457
ADMINISTRATOR/ DIRECTOR:	KARISMA G. ABRIGO		FACILITY TYPE:	735
ADDRESS:	655 BERKSHIRE PLACE		TELEPHONE:	(805) 271-9921
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 6		CENSUS: 4	DATE:	10/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:03 AM
MET WITH:	Vanessa Garcia		TIME VISIT/ INSPECTION COMPLETED:	02:00 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) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 10:03 AM. LPA met with facility staff who contacted facility backup administrator Vanessa Garcia via telephone call. Facility backup administrator arrived to the facility at 10:17 AM Entrance interview conducted and the reason for the visit was explained. Beginning at 10:17 AM, the LPA, along with facility backup administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: GARAGE: LPA observed the garage to be locked and inaccessible to clients in care. LPA observed the garage to contain three (3) secured cabinets, adequate emergency food and water supplies, an extra refrigerator, and the facility’s washer and dryer. LPA observed the secured cabinets to contain knives and other sharp objects, PRN medications and first aid supplies, and cleaning supplies and disinfectants. OUTDOOR SPACE: The facility has one (1) emergency exit gate, LPA observed clear passageways for emergency exit use. The facility has a patio with adequate shaded outdoor seating for resident use. KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed cabinets and drawers to contain food supplies, dishes, silverware, and extra kitchen towels. Report Continued on LIC 809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARING HOME	FACILITY NUMBER: 565801457
	VISIT DATE: 10/30/2024

NARRATIVE

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COMMON AREAS: This includes the living room, dining room, and hallway. LPA observed the living room to be clean and properly furnished at the time of the visit. LPA observed the living room to contain an appropriately screened fireplace, activities for resident use, and a secured cabinet containing additional resident files. Smoke detectors and carbon monoxide detectors were tested at 10:35 AM and were functional at the time of the visit. The dining room was observed to be clean and contains adequate seating for resident use. The hallway was observed to contain all required postings, one (1) properly secured cabinet and one (1) properly secured closet. LPA observed the secured cabinet to contain resident files and resident medications. LPA observed the closet to contain resident P&I resources. LPA observed a fire extinguisher in the hallway to be fully charged and serviced on 06/12/2024.

BEDROOMS: There are four (4) bedrooms in the facility; all are designated for resident use. Two (2) bedrooms are private rooms and two (2) bedrooms are dual occupancy rooms. LPA and facility staff toured all four (4) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a private resident bathroom and one (1) is designated as a common resident bathroom. Bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. The water temperature was measured in both bathrooms between 107.8 degrees Fahrenheit and 108.1 degrees Fahrenheit which is in compliance with regulation.

RECORD REVIEW: Record review began at 10:42 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Four (4) staff files were reviewed. All staff files contained the required documents and trainings. Four (4) resident files were reviewed. All resident files contained all required documentation and signatures. No deficiencies were observed during record review.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARING HOME	FACILITY NUMBER: 565801457
	VISIT DATE: 10/30/2024

NARRATIVE

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MEDICATION REVIEW / CASH RESOURCE REVIEW: Medication and cash resource review began at 11:40 AM. Medications are stored centrally and securely in a storage cabinet in the hallway. Medications for four (4) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. No deficiencies were observed during medication review. Cash resources were reviewed for four (4) residents, all cash resources observed were documented properly with the corresponding receipts. No deficiencies were observed during cash resource review.

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. Last emergency disaster drill was conducted on 10/07/2024. The facility’s emergency disaster plan was updated on 09/27/2024 and is adequate.

INTERVIEWS: LPA interviewed two (2) staff members. Both staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. No residents were available to interview at the time of the inspection.

During today’s visit LPA obtained a copy of the facility’s updated LIC500, resident roster, surety bond, and liability insurance.

No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

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