565802442-11-7-2023-29-AS-ECOZ-CXD23H-20231107160222

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802442
Report Date: 11/07/2023
Date Signed: 11/07/2023 04:03:08 PM

Document Has Been Signed on 11/07/2023 04:03 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:	R&J RESIDENTIAL CARE HOME		FACILITY NUMBER:	565802442
ADMINISTRATOR:	CARINO, CHRISTIAN RYAN		FACILITY TYPE:	740
ADDRESS:	2160 HANCOCK PL		TELEPHONE:	(805) 253-0483
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	4	CENSUS: 4	DATE:	11/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Michelle Viernes Co-Administrator		TIME COMPLETED:	04:15 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	At 09:45 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Administrator Christina Ellivera and informed them of the reason for the visit. Licensee Christian Carino arrived shortly. At 10:17 a.m. the LPA conducted a tour of the physical plant with the Administrator and Licensee to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of two (2) living rooms, four (4) resident bedrooms, one (1) staff room, one (1) communal restroom and two (2) resident restrooms. The LPA observed one (1) fire extinguishers which was fully charged and last serviced 12/19/2022. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallway near the entrance area. Kitchen: During the facility tour at 10:26 a.m. the kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are always available for the residents. Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: The LPA observed all bathrooms, properly supplied and with functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. At 10:34 a.m. water temperature in residents restroom was measured at 107.2 degrees Fahrenheit. The hot water measured was within the required limit of 105-120 degrees Fahrenheit. Report will continue on LIC809-C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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 6

Document Has Been Signed on 11/07/2023 04:03 PM - It Cannot Be Edited

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: R&J RESIDENTIAL CARE HOME	FACILITY NUMBER: 565802442
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as two staff did not have a health screening and TB negative results which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/14/2023
	Plan of Correction
1 2 3 4	Licensee agrees S2 will not work at the home until they obtain a health screening, and will submit proof of health screening for S1 and a copy of the schedule without S2 to LPA by 11/14/2023.

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	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 11/07/2023 04:03 PM - It Cannot Be Edited

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: R&J RESIDENTIAL CARE HOME	FACILITY NUMBER: 565802442
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in R1 missing admissions agreement and R2 missing appraisal needs and services plan which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/21/2023
	Plan of Correction
1 2 3 4	Licensee agrres to obtain admission agreement and appraisal needs and services plan and submit proof to LPA by 11/21/2023.

Type B

Section Cited

CCR

87465(d)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as all residents do not have a PRN authorization letter] which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/14/2023
	Plan of Correction
1 2 3 4	Licensee agrees to obatian PRN authorization letters for all residents in care and submit proof to LPA by 11/14/23.

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	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

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: R&J RESIDENTIAL CARE HOME	FACILITY NUMBER: 565802442
	VISIT DATE: 11/07/2023

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
26
27
28
29
30
31
32

Common Areas: These included the living rooms and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the first living room, which is covered with a screen. The facility maintained a comfortable temperature of 72 degrees. There were no obstructions and/or tripping hazards throughout the facility.
The garage: At 10:24 a.m. the LPA observed the garage, where the washer and dryer are held, and the emergency food and water is stored. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. The garage is not locked.
Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises.
Infection Control: The home has an adequate supply of Personal Protection Equipment (PPE) and can obtain additional supplies. The home’s policies and procedures pertaining to infection control were adequate.
Medications: At 10:44 a.m. a medications review was initiated. Medications are centrally stored and locked in a cabinet in the kitchen; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. The LPA observed all residents have PRN medications and the facility does not have PRN Authorization Letters on file to indicate whether the residents are able to make their own decision or if the doctor needs to be contacted prior to assisting the residents with the PRN medications.
Record Review: At 11:23 p.m. a review of facility files was initiated. The LPA reviewed four (4) out of four (4) resident files. One out four residents (R1) did not have an admission agreement on file and one out of four residents (R2) did not have an appraisal/needs and services plan. The LPA reviewed five (5) of seven (7) staff files. Two out five staff (S1,S2) did not have a health screening with Tuberculosis results on file. Staff was observed to be missing dementia training. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 10/15/2023). The LPA obtained a Client Roster and Staff Roster.
Interviews: At 02:20 p.m. the LPA conducted two (2) staff and one (1) resident Interviews. No immediate concerns were voiced.

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 to Licensee Christian Carino.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

Page: 6 of 6