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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802427
Report Date: 05/05/2021
Date Signed: 05/05/2021 02:46:31 PM

Document Has Been Signed on 05/05/2021 02:46 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:DELPHINIUM MANORFACILITY NUMBER:
565802427
ADMINISTRATOR:GONZALES, HERMIFACILITY TYPE:
740
ADDRESS:691 DELPHINIUM PLTELEPHONE:
(805) 919-9770
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: 6CENSUS: 6DATE:
05/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Hermi GonzalesTIME COMPLETED:
12:10 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
This Case management visit was conducted to address the deficiencies noted during complaint control # 29-AS-20210427084005 investigation visit conducted on 5/5/21.

During facility tour on 5/5/21 starting at 9:38 AM LPA's observed spray chemicals in a bucket outside bathroom accessible to residents. At 9:50 AM LPA's observed laundry soap, vinegar, Lysol toilet bowl cleaner, and other chemicals in an unlocked garage door accessible to residents. At 9:52 AM LPA's observed disinfectant and cleaning solutions stored in a food storage area inside garage. At 9:55 AM LPA's observed fertilizer bag, a propane tank and gardening tools in outside patio accessible to residents.

During the review of resident records on 5/5/21, starting at 10:25 AM, LPA's observed R1, R2 and R3 Physicians Report and Appraisal Reports not currently dated.


Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies was cited (refer to LIC 809-D):

Exit interview conducted, todays reports reviewed and email to administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2021
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 3
Document Has Been Signed on 05/05/2021 02:46 PM - It Cannot Be Edited


Created By: Angel Ascencio On 05/05/2021 at 11:05 AM
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: DELPHINIUM MANOR
FACILITY NUMBER: 565802427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2021
Section Cited
CCR
87705(f)(2)

1
2
3
4
5
6
7
87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by
1
2
3
4
5
6
7

Staff placed items in an inaccessible location during facility visit. Administrator stated that she will provide documentation of scheduled staff training regarding regulation 87705(f)(2).
8
9
10
11
12
13
14
Based on LPA's observations, the licensee did not comply with the section cited above, 5 out of 6 residents have a diagnosis of dementia according to physicians report, and toxic substances were observed throughout the facility accessible to residents which posed an immediate health risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 05/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/05/2021 02:46 PM - It Cannot Be Edited


Created By: Angel Ascencio On 05/05/2021 at 11:19 AM
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: DELPHINIUM MANOR
FACILITY NUMBER: 565802427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2021
Section Cited
CCR
87705(c)(5)

1
2
3
4
5
6
7
87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually...

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Admin stated they will provide copies of R1, R2 and R3 current signed annual medical assessment and appreasals.
8
9
10
11
12
13
14
Based on record review, the licensee did not comply with the section cited above in 3 out of 6 resident records which poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
Type B
05/19/2021
Section Cited
CCR87309(c)

1
2
3
4
5
6
7
87309 Storage Space (c) The items specified in (a) above shall not be stored in food storage areas or in storage areas used by or for clients.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Admin stated they will provide photo of partician dividing food storage and disinfectant and cleaning solutions.
8
9
10
11
12
13
14
Based on LPA's observations, the licensee did not comply with the section cited above as disinfectant and cleaning solutions were observed in a food storage which poses a potential safety 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3