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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802451
Report Date: 01/12/2024
Date Signed: 01/12/2024 05:05:47 PM

Document Has Been Signed on 01/12/2024 05:05 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:PHOENIX8-1,LINCOLNFACILITY NUMBER:
565802451
ADMINISTRATOR:SUSANA L. MIXFACILITY TYPE:
735
ADDRESS:1900 LINCOLN CTTELEPHONE:
(805) 488-3923
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 9CENSUS: 5DATE:
01/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Susana L. MixTIME COMPLETED:
05:15 PM
NARRATIVE
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At 11:40 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required - 1 Year Annual inspection at the facility today. The LPA met with Administrator Susie Mix and informed them of the reason for the visit. The home is vendored by Tri-Counties Regional Center as a level 4-C home.

At 11:50 a.m. the LPA toured the physical plant areas inside and outside with the Administrator to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers were throughout the facility which were fully charged and purchased on March 16. 2023. All smoke alarms and carbon monoxide detectors were tested and functioned properly. LPA observed all required postings in the living room.

KITCHEN: Knives are stored in a locked drawer. The kitchen appeared cleaned and the facility has a sufficient supply of perishable and non-perishable food. The LPA observed the dish washer machine inoperable.

BEDROOMS: The LPA observed six client bedrooms and one staff office. Client rooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The LPA observed a window screen not properly installed in room #2.

RESTROOMS: There is one common restroom and two private restrooms for client use. The restrooms were clean and sanitary with hand soap and paper towels. At 12:18 p.m. the hot water temperature tested in the common restroom measured at 101.2 degrees F. At 12:38 p.m. the hot water temperature tested in one of the private restrooms measured at 94.4 degrees F.

COMMON SPACES: Living room and dining room furniture was observed to be in good condition. Required signs were posted. Cleaning supplies were observed to be locked in the garage and inaccessible to clients in care. The backyard has covered seating for client use.


Report will continue on LIC809-C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2024
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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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: PHOENIX8-1,LINCOLN
FACILITY NUMBER: 565802451
VISIT DATE: 01/12/2024
NARRATIVE
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Record Review: At 02:20 p.m., a review of facility files was initiated. Facility records are stored in the locked office. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 08/20/2023). The LPA obtained Client Roster, and Staff Roster. The LPA reviewed five (5) of five (5) staff Files. The LPA could not verify the Administrators current HIV /TB training (minimum 4 hours). The LPA observed that one out of five staff files (S1) did not have a criminal record clearance and was not associated to the facility. Guardian records indicate S1's criminal record clearance application was incomplete and there is no record of S1 being associated to this facility in the past. The LPA reviewed five (5) out of (5) five client files. All client documents reviewed appeared complete and current.

Interviews: During the visit the LPA conducted one (1) client interview. No immediate concerns voiced at this time.



Due to time constraints the LPA will return to complete the annual at a later date.

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 the Administrator.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/12/2024 05:05 PM - It Cannot Be Edited


Created By: Esther Cortez On 01/12/2024 at 04:31 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: PHOENIX8-1,LINCOLN
FACILITY NUMBER: 565802451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as S1 has been working at the facility since 8/18/23 without approved criminal record clearance and association to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/13/2024
Plan of Correction
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Administrartor agreed to have staff 1 (S1) background fingerprint cleared and associated to work at the facility before working in the facility and a written declaration ensuring all staff will have a background clearance and be properly associated to the facility prior to working, residing, or volunteering in the facility will be submitted via email to LPA no later than 01/13/2024 at 4:00 pm.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/12/2024 05:05 PM - It Cannot Be Edited


Created By: Esther Cortez On 01/12/2024 at 04:31 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: PHOENIX8-1,LINCOLN
FACILITY NUMBER: 565802451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024

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
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Based on observation, the licensee did not comply with the section cited above as two client restrooms water temperature was below 105 degrees F. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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The Administrator agreed to do the following:
1. Adjust the water tank within the next 24 hours
2. After adjusting the water, keep a five (5) day temperature log and submit to CCL within the next seven days.
Type B
Section Cited
HSC
1562.5(a)
Other Provisions
(a) The director shall ensure that, within six months after obtaining licensure, an administrator of an adult residential facility and a program director of a social rehabilitation facility shall receive four hours of training on the needs of residents who may be infected with the human immunodeficiency virus (HIV), and on basic information about tuberculosis. Administrators and program directors shall attend update training sessions every two years after satisfactorily completing the initial training to ensure that information received on HIV and tuberculosis remains current. The training shall consist of three hours on HIV and one hour on tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the administrator did not have any HIB/TB training on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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Administrator agreed to update and complete HIV and TB training by POC date. Submit copy of certificate to CCL by POC date.
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
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024


LIC809 (FAS) - (06/04)
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