565801727-3-25-2022-29-AS-KLOZ-CCUQ3H-20220325114845

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801727
Report Date: 03/25/2022
Date Signed: 03/25/2022 01:29:19 PM

Document Has Been Signed on 03/25/2022 01:29 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:	SAINT ROQUE FAMILY HOME CARE		FACILITY NUMBER:	565801727
ADMINISTRATOR:	BARBARA BROWNING		FACILITY TYPE:	735
ADDRESS:	1610 KIPLING COURT		TELEPHONE:	(805) 874-1762
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 6		CENSUS: 6	DATE:	03/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Veronica Decano		TIME COMPLETED:	11:55 AM

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required -1 Year inspection at the facility today. The LPA met caregiver Veronica "Jam" Decano at 10:25 AM and explained the reason for today's visit. Administrator Barbara Browning was contacted at 10:27 AM but was not available by phone.

At 10:28 AM, the LPA, along 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. This annual Required - 1 Year inspection has a specific emphasis on infection control practices and procedures. The following was observed:

KITCHEN: Beginning at 10:28 AM, the kitchen and food storage areas in the garage were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen and garage. Cleaning supplies and items that could pose a danger were secured and locked in the garage or locked storage.

Common Areas: The living room area has sufficient seating for the residents and was free of obstruction. Medications are in a locked cabinet in the living room. Beginning at 10:38 AM, the carbon monoxide detector in the hallway and the smoke detectors in the resident bedrooms, living room, and hall way were tested and operational. The fire extinguisher is fully charged but last serviced 02/24/2021. During the inspection, the LPA noticed the digital thermostat in the hallway did not light up and did not appear to be functional. The caregiver turned on the heater using the thermostat and the heater did not turn on. The LPA spoke with Client #1 (C1) who stated the home did not have a functioning heater and they used their blankets when they got cold.

Common Restroom: There is one common hallway restroom for resident use. The restroom had a supply of hand soap and paper towels. Signs regarding infection control and hand washing where posted. The light in the bathroom near the shower was operational. Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

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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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: SAINT ROQUE FAMILY HOME CARE	FACILITY NUMBER: 565801727
	VISIT DATE: 03/25/2022

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Bedrooms: Resident bedrooms were found to be appropriately furnished and had lighting. A cupboard with clean linen and towels was located outside the resident bedrooms.

Infection Control: During today’s visit, the LPA spoke with the caregiver regarding the facility’s infection control practices. The caregiver stated they are cleaning frequently touched areas daily. Light switches and door handles had no visible dirt. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE). The facility’s cleaning protocol is sufficient. Infection control signs were posted at the entry, throughout the facility, and in the restrooms. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

The following deficiencies were observed (See LIC 809-D.) 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 and report reviewed with the caregiver. A copy of the report and appeal rights were emailed to the Administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/25/2022 01:29 PM - It Cannot Be Edited

Created By: Kasandra Lopez On 03/25/2022 at 11:24 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: SAINT ROQUE FAMILY HOME CARE	FACILITY NUMBER: 565801727
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(a)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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the heater is not functional and the fire extinguisher needs to be serviced which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/01/2022
	Plan of Correction
1 2 3 4	The caregiver contacted the Administrator during the inspection and a maintenance person is coming today to look at the heater. The caregiver will submit proof by the end of the day that someone has inspected the heater. The Administrator shall submit proof the heater is functional and the fire extinguisher is serviced by 4/1/2022.

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: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC809 (FAS) - (06/04)

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