565801556-4-14-2023-29-AS-KLOZ-CQVTSQ-20230414145931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801556
Report Date: 04/14/2023
Date Signed: 04/14/2023 04:29:17 PM

Document Has Been Signed on 04/14/2023 04:29 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:	DOLORES FAMILY HOME		FACILITY NUMBER:	565801556
ADMINISTRATOR:	REBECCA G. HERNANDEZ		FACILITY TYPE:	735
ADDRESS:	4540 FROST DRIVE		TELEPHONE:	(805) 488-3947
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 4		CENSUS: 4	DATE:	04/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Vanessa Garcia		TIME COMPLETED:	03:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required - 1 Year inspection at the facility today. The LPA met with caregiver Maria Hernandez and explained the reason for the inspection. Assistant Administrator Vanessa Garcia arrived at approximately 12:45 PM. The administrator of record is currently on leave.

At 12:42 PM, the LPA, along with the caregiver toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. There is currently one staff and two clients present in the facility.

Kitchen The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives and items that could pose a danger were secured in locked cabinets. Medications and facility records are stored in a locked cabinet in the dining area.

Common Areas: In the common areas, furniture, walls, and flooring were clean and in good condition at the time of the inspection. All indoor and outdoor passages were free of obstruction. The fire extinguisher was fully charged and last serviced on 07/06/2022. Infection control signs are posted through out the facility. At 12:50 PM the carbon monoxide detector and smoke alarms in the common rooms and bedrooms were tested and operational. The facility has one common and one private restroom for client use. Restrooms were observed to be clean and sanitary with hand soap and paper towels. The hot water temperature in the common restroom measured at 128.7 degrees F. Cleaning supplies and disinfectants are stored in locked cabinets in the garage. The backyard has covered seating for client use. Infection control practices were discussed.

Bedrooms: The LPA observed the three client bedrooms. They were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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 04/14/2023 04:29 PM - It Cannot Be Edited

Created By: Kasandra Lopez On 04/14/2023 at 02:26 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: DOLORES FAMILY HOME	FACILITY NUMBER: 565801556
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2023

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the hot water temperature in the common hallway restroom measured at 128.7 degrees F which poses an immediate health and safety risk to persons in care.
	POC Due Date: 04/21/2023
	Plan of Correction
1 2 3 4	The hot water heater was turned down during the inspection. The licensee shall submit proof of a five day water temperature log indicating the water temperature is within the required range of 105-120 degrees F. to CCL by 04/21/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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: DOLORES FAMILY HOME	FACILITY NUMBER: 565801556
	VISIT DATE: 04/14/2023

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MEDICATIONS: Medications are locked and centrally stored in the dining room. At 1:00 PM medications for two clients were reviewed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record. The LPA inspected the first aid kit, which was complete.

RECORDS: At 1:37 PM record review for four clients and five staff was conducted. Client files reviewed were found to be complete. P&I money and records were reviewed. Cash resources were separate and intact, and not be commingled with facility funds or petty cash. The facility has a surety bond on file. Staff files reviewed were complete. Disaster drills are conducted quarterly.

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 809-D. Exit Interview conducted and the report was reviewed with the Vanessa Garcia. Appeal Rights and a copy of this report has been issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

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