565850255-7-16-2023-29-AS-KDUK-CTSTX5-20230716150633

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850255
Report Date: 07/16/2023
Date Signed: 07/16/2023 03:06:55 PM

Document Has Been Signed on 07/16/2023 03:06 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:	CALIFORNIA CARE RCFE BAXTER		FACILITY NUMBER:	565850255
ADMINISTRATOR:	OBTINALLA, MC RICHARD		FACILITY TYPE:	740
ADDRESS:	283 BAXTER STREET		TELEPHONE:	8184482967
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91320
CAPACITY:	6	CENSUS: 5	DATE:	07/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:21 AM
MET WITH:	Arnida Obtinalla & MC Richard Obtinalla		TIME COMPLETED:	03:15 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	Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 10:21AM. LPA was greeted by Facility Designee Arnida Obtinalla. Licensee MC Richard Obtinalla was contacted via telephone and arrived at the facility at approximately 12:40PM. Entrance interview conducted. Beginning at 10:30AM, the LPA, along with Facility Designee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: LAUNDRY & GARAGE: The laundry room is located adjacent to the kitchen. Laundry supplies and chemicals are stored in a locked cabinet, inaccessible to residents in care. Garage was observed locked and contained an additional freezer and pantry, as well as staff lounge and office area. KITCHEN: The LPA observed the kitchen/dining area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food and emergency water. The LPA observed one designated cabinet under the kitchen island where knives and sharps are stored locked and inaccessible to residents. Cleaning supplies are located in a locked cabinet under the kitchen sink. COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be relatively clean and properly furnished at the time of the visit. No fireplace was noted. The LPA observed the fire extinguishers to be fully charged and last serviced on 05/31/2023. Hardwired smoke detectors and carbon monoxide detector were tested at 01:23 PM and were functional at the time of the visit. Last emergency disaster drill was conducted 04/22/2023 and another will be conducted this month. Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2023

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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Document Has Been Signed on 07/16/2023 03:06 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CALIFORNIA CARE RCFE BAXTER	FACILITY NUMBER: 565850255
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(6)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. 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 2 residents with a diagnosis of dementia did not contain proof of an annual medical assessment, nor reappraisal, which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Facility Designee indicated that both residents have scheduled medical appointments upcoming, at which point the medical assessments will be completed. Licensee/Designee will complete the reassessments for both residents and send proof of completion of all listed items to CCL by POC due date.

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	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2023

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: CALIFORNIA CARE RCFE BAXTER	FACILITY NUMBER: 565850255
	VISIT DATE: 07/16/2023

NARRATIVE

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Continued from LIC 809

BEDROOMS: There are five (5) bedrooms in the facility; four (4) bedrooms are designated for resident use, including two (2) shared rooms, and two (2) private rooms, as well as one (1) staff room. The staff room is kept locked. All 4 (four) resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

BATHROOMS: There are two (2) bathrooms for resident use, one (1) of which is a shared resident restroom located in the hallway and one (1) is a private resident restroom. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in the shared resident bathroom and measured at 116.1 degrees Fahrenheit, which is in compliance with regulation.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. Facility has two total gates, one (1) gate was observed to be self-latching and closing with clear passageways for emergency exit use. There were no bodies of water on the premises at the time of the visit.

RECORD REVIEW: Began at 10:50AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Resident files for two (2) residents, both of which have a diagnosis of dementia, did not contain an annual medical appraisal nor an annual needs and service appraisal. Facility Designee indicated both residents have upcoming medical appointments scheduled, during which the annual medical assessment will be completed.

MEDICATION REVIEW: Began at 12:45PM. Medications for five (5) of five (5) residents were observed. Over the Counter medication for all residents were not properly labeled at the time of the visit. LPA advised the Licensee on proper labeling.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2023

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: CALIFORNIA CARE RCFE BAXTER	FACILITY NUMBER: 565850255
	VISIT DATE: 07/16/2023

NARRATIVE

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Continued from LIC 809-C

facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate.

INTERVIEWS: LPA interviewed two (2) staff and one (1) resident.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Licensee was advised that failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2023

LIC809 (FAS) - (06/04)

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