565802410-1-11-2022-29-AS-AASO-CAKMEH-20220111083246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802410
Report Date: 01/10/2022
Date Signed: 01/11/2022 08:34:53 AM

Document Has Been Signed on 01/11/2022 08:34 AM - 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:	PEOPLE'S CARE GOODENOUGH		FACILITY NUMBER:	565802410
ADMINISTRATOR:	JOSHUA CRATION		FACILITY TYPE:	735
ADDRESS:	2591 GOODENOUGH RD		TELEPHONE:	(805) 524-5617
CITY:	FILLMORE	STATE: CA	ZIP CODE:	93015
CAPACITY: 6		CENSUS: 5	DATE:	01/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Tanya Kramer		TIME COMPLETED:	02:50 PM

NARRATIVE

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Licensing Program Analysts (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 12:35 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with a staff member as Admin Joshua Cration was unavailable. House Lead arrived at the facility at 2:05 p.m. Discussed reason for the visit. Entrance interview conducted.

The LPA, along with staff, toured the physical plant areas inside and outside at 12:40 p.m. to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) total bedrooms for resident use – 4 (four) are private rooms in the permanent side and 2 (two) private rooms in the crisis.

RESTROOMS: There are 3 public restrooms for resident use. All restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPA observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year.

The backyard has a covered outdoor area equipped with furniture for resident use. There is a body of water with a locked gate. Laundry room contains a locked storage cabinet for laundry supplies. Fire alarms were checked and working properly at the time of visit.

Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

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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Document Has Been Signed on 01/11/2022 08:34 AM - It Cannot Be Edited

Created By: Angel Ascencio On 01/10/2022 at 01:43 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: PEOPLE'S CARE GOODENOUGH	FACILITY NUMBER: 565802410
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as 2 out of 3 restrooms water temperature did not measure within 105 degrees F and 120 degrees F which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/21/2022
	Plan of Correction
1 2 3 4	House Lead stated they will increase the temperature for the restroom near the entrance. House lead will also decrease the water temperature in the crisis hand washing area. Staff will take temperature readings 3 times a day for 3 days and send resutls to LPA via email.

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:

Kristin Heffernan

LICENSING EVALUATOR NAME:

Angel Ascencio

LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

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: PEOPLE'S CARE GOODENOUGH	FACILITY NUMBER: 565802410
	VISIT DATE: 01/10/2022

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Medication was also observed to have at least a 30-day supply.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the staff member regarding the facility’s infection control practices at 1:45 pm. There are 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. LPA noted that the facility is allowing visitors for outdoor visitation only. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. 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 has not had a confirmed case of COVID-19 at this time.

The following deficiencies were observed (See LIC 9099-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.

1 (one) citation was issued during today’s visit. Exit interview conducted. A copy of the report was provided via email to admin.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

LIC809 (FAS) - (06/04)

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