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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801727
Report Date: 12/28/2021
Date Signed: 12/28/2021 07:36:09 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/28/2021 07:36 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 CAREFACILITY NUMBER:
565801727
ADMINISTRATOR:BARBARA BROWNINGFACILITY TYPE:
735
ADDRESS:1610 KIPLING COURTTELEPHONE:
(805) 874-1762
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
12/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Veronica "Jam" DecanoTIME COMPLETED:
02:35 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 10:57 AM and explained the reason for today's visit. Administrator Barbara Browning was contacted at 11:00 AM but stated she was unable to come to the facility for today's inspection. At 11:02 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. The following was observed:

Kitchen/Dining area: The LPA began touring the dining and kitchen area. 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 in the garage. There is sufficient seating for resident dining. Knives and sharp items are locked in the garage. Cleaning supplies are stored in a locked cabinet under the sink and in locked cabinets in the garage.

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 11:20 AM, the carbon monoxide detector in the hallway and the smoke detectors in the resident bedrooms, living room, and staff room were tested and operational. The hallway was missing a functioning smoke detector. Staff stated the smoke alarm recently broke and was removed from the hallway ceiling. Staff replaced the battery in the detector during the inspection but it still not functioning properly. The backyard has seating for resident use and was free of obstruction. Extra Hygiene items were observed locked in the garage. Fire extinguisher is fully charged and last serviced 02/24/2021.

Common Restroom: There is one common hallway restroom for resident use. The hot water temperature measured at 116.6 degrees F. The restroom floor, walls, toilet, and shower were found to be visibly dirty and the bathroom smelled like urine. Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2021
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 12/28/2021 07:36 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 12/28/2021 at 01:54 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: 12/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/04/2022
Section Cited
CCR
80065(f)(1-7)

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80065 Personnel Requirements (f)(1-7) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidenced by
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The administrator shall submit proof S1 has received training pursuant to 80065(f)(1-7) by 01/04/2022.
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Based on record review, the licensee failed to comply with the section cited above, as one staff (S1) out of two staff did not have documentation of training which poses a potential health, safety, and personal rights risk to residents in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/28/2021 07:36 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 12/28/2021 at 01:31 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: 12/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/28/2021
Section Cited
CCR
80020(a)

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80020 Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
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The licensee/administrator shall submit proof the hallway has a functioning smoke detector. This is an immediate civil penalty assessment of $500 and civil penalties will continue to accrue until the correction is received. (see LIC 421M)
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Based on observation, the licensee failed to comply with the section cited above as the hallway did not have a functioning smoke alarm which poses an immediate safety risk to residents in care.
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Type A
01/04/2022
Section Cited
CCR80087(a)

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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:
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The caregiver agrees to immediately clean the bathroom so it is free of the smell of urine and clean all frequently touched surfaces with disinfectant. By 01/04/22, the administrator shall submit proof the bathroom, shower, walls, and resident doors are deep cleaned, and the second light in the bathroom is working.
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Based on observation, the licensee failed to comply with the section cited above as the restroom, doors, and light switches were observed to have smell and/or visibly dirty, commonly touched areas are not cleaned daily, and the second light in the bathroom which poses an immediate health and personal rights risk to residents in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2021


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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: 12/28/2021
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The caregiver stated they clean the bathroom daily but the residents are not compliant with proper hygiene practices. The light in the bathroom near the shower was not operational.


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

Medication Review: At 11:51 AM, medications for five out of the six residents was reviewed. One resident does not receive medications at the facility. Medications are locked and centrally stored in a cabinet in the living room. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications were recorded on the centrally stored medication and destruction record.

Facility Records: Record review began at 12:09 PM. All six resident files were reviewed and were found to be complete. Two staff files were reviewed. Staff had current first aid and CPR cards. Staff #1 (S1) had no written documentation of training. S1 stated they only had verbal training. Disaster drills are conducted monthly, the last drill being conducted on 12/11/2021.

Infection Control: During today’s visit, the LPA spoke with the caregiver regarding the facility’s infection control practices. Frequent touched areas like door knobs and light switches are not being cleaned daily and the light switches in the dining room were observed to be visibly dirty. Upon entry, the facility has a central entry point for symptom screening. LPA observed staff to be wearing a mask. The LPA observed an adequate supply of Personal Protective Equipment (PPE). 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: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
LIC809 (FAS) - (06/04)
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