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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801727
Report Date: 03/07/2024
Date Signed: 03/07/2024 05:21:26 PM

Document Has Been Signed on 03/07/2024 05:21 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:SAINT ROQUE FAMILY HOME CAREFACILITY NUMBER:
565801727
ADMINISTRATOR:BARBARA BROWNINGFACILITY TYPE:
735
ADDRESS:1610 KIPLING COURTTELEPHONE:
(805) 874-1762
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
03/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Barbara BrowningTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required -1 Year inspection at the facility today. The LPA met with staff Carmen Constantino at 2:10 PM and explained the reason for the visit. Administrator Barbara Browning was contacted and arrived at the facility at approximately 2:54 PM.

The LPA, along the administrator, 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.

Common Areas: The living room area has sufficient seating for the residents, 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 February 20, 2023.

Restroom: There is one common hallway restroom for resident use. The restroom had a supply of hand soap and paper towels. At 3:49 PM, hot water measured at 124.2 degrees F. The LPA observed the restroom unsanitary with residue on the floor, sink and toilet.

Report will continue on LIC809-C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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: SAINT ROQUE FAMILY HOME CARE
FACILITY NUMBER: 565801727
VISIT DATE: 03/07/2024
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Bedrooms: Resident bedrooms were observed. The LPA observed all resident rooms with dust on furniture, residue on the floors, and observed one of the resident rooms with spider webs on the outside of the closet in the corner.

Garage/Outside: The LPA observed the garage where the washer and dryer are held and an extra refrigerator and freezer. At 3:10 p.m. the LPA observed Arm & harmer laundry detergent in the garage, the garage is kept unlocked during the day. The backyard has covered seating for resident use. There are no bodies of water on the premises. At 3:38 p.m. the LPA observed Zerex antifreeze coolant and Mobil Advanced Full Synthetic motor oil.

Due to time constraints the LPA will return at a later date to complete the annual.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/07/2024 05:21 PM - It Cannot Be Edited


Created By: Esther Cortez On 03/07/2024 at 04:53 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: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 LPA observed laundry detergent, antifreezer coolant, and motor oil accessible to the clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Plan of correction is met. The administrator locked the garage and threw away the anti freezer and motor oil.
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
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Based on observation, the licensee did not comply with the section cited above as the hot water measured at 124.2 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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The administrator agrees to adjust the water temperature and submit proof to the LPA by 03/08/2024.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/07/2024 05:21 PM - It Cannot Be Edited


Created By: Esther Cortez On 03/07/2024 at 04:53 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: 03/07/2024

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 LPA observed the bedrooms and restroom floors visibly dirty, residents furniture observed with large amount of dust, and observed spider webs in one of the residents rooms, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2024
Plan of Correction
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Administrator agrees to have a plan in place with residents to schedule resident room cleaning and submit proof that the resident rooms and bathroom have been cleaned.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
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