<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801844
Report Date: 04/27/2023
Date Signed: 04/27/2023 01:21:13 PM

Document Has Been Signed on 04/27/2023 01:21 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:JN GONZALES HOMEFACILITY NUMBER:
565801844
ADMINISTRATOR:AMANDA G. LEEFACILITY TYPE:
735
ADDRESS:4231 NIMITZ DRIVETELEPHONE:
(805) 488-0236
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
04/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Vanessa GarciaTIME COMPLETED:
01:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management Deficiencies inspection. Tri-Counties Regional Center Quality Assurance Specialist (QAS) Liz Aced-Arnett was also present. Administrator Vanessa Garcia arrived at 12:50 PM.

During the an unannounced complaint investigation inspection, LPA Lopez and QAS Aced-Arnett observed there to be three staff and six clients present. The home is vendored by Tri-Counties Regional Center as a level 4-I home. Currently the home has two individuals who require 1:1 support, leaving one staff to supervise four clients. The staff schedule reviewed indicated between 12:00PM-1:00 PM there should be five staff present. During the visit another staff arrived at the facility to make there a total of four staff in the home.

Also at 12:30 PM, keys that unlock the medication cabinets and records were in an unsecured drawer in the kitchen.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/27/2023 01:21 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 04/27/2023 at 12:55 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: JN GONZALES HOME
FACILITY NUMBER: 565801844

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2023
Section Cited
CCR
80065(a)

1
2
3
4
5
6
7
80065 Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement is not met as evidenced by
1
2
3
4
5
6
7
The administrator agrees to submit a written plan on how they will prevent the home from being insufficiently staff to CCL by 05/10/2023.
8
9
10
11
12
13
14
Based on observation and record review, the licensee failed to comply with the section cited above as the facility was insufficiently staffed with only three staff for six clients which poses a potential health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
05/10/2023
Section Cited
CCR80072(a)(2)

1
2
3
4
5
6
7
80072 Personal Rights
(a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
The administrator agrees to do an in-service training for staff regarding keeping the keys secured at all times. Proof of training shall be submitted by 05/10/2023.
8
9
10
11
12
13
14
Based on observation, the licensee failed to comply with the section cited above as keys that unlock the medication cabinet were in an unsecured kitchen drawer which poses a potential health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2