565802471-8-4-2023-29-AS-KLOZ-CUDR5B-20230804124253

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802471
Report Date: 08/04/2023
Date Signed: 08/04/2023 04:40:33 PM

Document Has Been Signed on 08/04/2023 04:40 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:	ARIANNA KAY HOME		FACILITY NUMBER:	565802471
ADMINISTRATOR:	CAFUIR, DELIA		FACILITY TYPE:	735
ADDRESS:	4621 CONCORD WAY		TELEPHONE:	(805) 246-8490
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 4		CENSUS: 4	DATE:	08/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Melanie Cafuir		TIME COMPLETED:	12:50 PM

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required - 1 Year inspection at the facility today. When the LPA arrived there were two staff and two clients present. The other clients were attending their day program. Assistant Administrator Melanie Cafuir arrived during the inspection. This home is vendored by Tri-Counties Regional Center as a level four home.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen and garage. Cleaning supplies and items that could pose a danger were secured in a locked cabinet under the kitchen sink. The facility has a supply of emergency food and water.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and condition. All indoor and outdoor passages were free of obstruction. At the time of the visit, living room and dining room furniture was observed to be in good condition. The fire extinguishers were fully charged and last serviced on 04/04/2023. The carbon monoxide detector and smoke detectors in the home and bedrooms were tested at 10:25 AM and were operational. Medications are centrally stored and in a locked cabinet in the kitchen. Cleaning supplies were observed to be locked in the garage and inaccessible to client in care. The backyard has covered seating for client use.

BEDROOMS: There are three client bedrooms and one staff bedroom. The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. During the inspection at 10:15 AM, the LPA observed several containers of over the counter vapor rub in bedroom #1. The items were removed and secured in the medication cabinet.

Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARIANNA KAY HOME	FACILITY NUMBER: 565802471
	VISIT DATE: 08/04/2023

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RESTROOMS: The facility has one common restrooms for client use. The restroom was observed to be clean and sanitary with hand soap, toilet paper and paper towels. The hot water temperature in the common hallway restroom measured at 118 degrees F.

MEDICATIONS: Medications are locked and centrally stored in a locked cabinet in the kitchen area. At 10:26 AM medications for four clients were reviewed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record. The LPA inspected the first aid kit, which was complete.

RECORDS: At 12:05 PM, the LPA reviewed P&I money and records with the staff. Cash resources for all four clients were separate and intact, and not be commingled with facility funds or petty cash. The facility has a current surety bond on file. The four client files reviewed were found to be complete. Five staff files reviewed were also found to be complete. Disaster drills are conducted quarterly. The facility has a 30 day supply of personal protective equipment and an emergency disaster plan on file.

INTERVIEWS: Interviews with one staff was conducted. No issues or concerns revealed. The second staff and two clients left for an outing during the inspection therefore, unable to be interviewed.

The following deficiency was cited from the CA Code of Regulations. See LIC 809-D. Exit interview conducted and report reviewed with the Co-Administrator. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/04/2023 04:40 PM - It Cannot Be Edited

Created By: Kasandra Lopez On 08/04/2023 at 12:09 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: ARIANNA KAY HOME	FACILITY NUMBER: 565802471
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(k)(1)

Health-Related Services

(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 over the counter vapor rub was found in bedroom #1 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/04/2023
	Plan of Correction
1 2 3 4	The items were secured during the inspection. Plan of correction is cleared.

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:

Desaree Perera

LICENSING EVALUATOR NAME:

Kasandra Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC809 (FAS) - (06/04)

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