565801727-1-20-2023-29-AS-KLOZ-CNA2JA-20230120162602

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801727
Report Date: 01/20/2023
Date Signed: 01/20/2023 04:27:26 PM

Document Has Been Signed on 01/20/2023 04:27 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:	01/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:33 PM
MET WITH:	Barbara Browning		TIME COMPLETED:	03:35 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 caregiver Veronica "Jam" Decano at 1:33 PM and explained the reason for today's visit. Administrator Barbara Browning was contacted and arrived at the facility at approximately 1:50 PM.

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.

KITCHEN: The kitchen and food storage areas in the garage were observed. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of perishable and non-perishable food. Kitchen knives are stored in the locked pantry. 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. The facility also has a TV room area near the dining room area with two couches for resident use. 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 March 28, 2022.

Common Restroom: There is one common hallway restroom for resident use. The restroom had a supply of hand soap and paper towels. At 1:48 PM, hot water measured at 113.8 degrees F. 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: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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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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: 01/20/2023

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Bedrooms: Resident bedrooms were observed. The sliding glass door in bedroom #2 leading to the backyard was found to have a missing door. The opening only had a magnetic screen as a door exposing the residents to the outside elements. The Administrator stated the door has been broken for a couple of months. She said the licensee was aware and they had only received a quote for a repair. Staff said the glass on the slider broke and the door frame was removed. Photos of the area were taken by the LPA.

The Administrator contacted Licensee Christine Reyes-Bonilla at 2:01 PM. The Licensee stated she was in a work meeting and could not talk. The LPA informed the Licensee that this was an emergency and the LPA needed to know immediately what the plan was to fix the door. The Licensee stated they will contact someone today to initiate the repair. The Administrator contacted the facility handy man during the visit and left him a message. The Administrator also contacted a company to receive a quote for the repair.

The LPA discussed options with the Administrator regarding sleeping arrangements for the residents until the door is repaired. There are currently two residents residing on bedroom #2. The home has two separate common areas with couches which the residents can use at night when sleeping in order to protect them selves from the cold at night.

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. 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 deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. This deficiency warrants an immediate civil penalty. This is a repeat violation of the same citation that was issued on 03/25/2022 which is within a twelve (12) month period. Therefore, civil penalties are being assessed in the amount of $500. Failure to correct the deficiency may result in additional civil penalties. Exit interview and report reviewed with the Administrator. A copy of the report and appeal rights were emailed due to printer issues.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/20/2023 04:27 PM - It Cannot Be Edited

Created By: Kasandra Lopez On 01/20/2023 at 03:10 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: SAINT ROQUE FAMILY HOME CARE	FACILITY NUMBER: 565801727
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above as the slider is broken in bedroom #2 exposing the residents to the outside elements which poses an immediate health, safety, and personal rights risk to residents in care.
	POC Due Date: 01/27/2023
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit proof the door has been repaired to CCL by 01/27/2023. Failure to correct the deficiency may result in additional civil penalties. This is a repeat violation of a citation issued on 03/25/2022. Subsequent violations within a twelve (12) month period will result in a civil penalty in the amount of $500.

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: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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