565850269-6-15-2024-29-AS-ECOZ-D69TRP-20240615145753

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850269
Report Date: 06/15/2024
Date Signed: 06/15/2024 02:58:44 PM

Document Has Been Signed on 06/15/2024 02:58 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:	KINDCARE SENIOR HOME		FACILITY NUMBER:	565850269
ADMINISTRATOR:	MARILOU ROJAS		FACILITY TYPE:	740
ADDRESS:	4810 JUSTIN WAY		TELEPHONE:	(323) 236-9397
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 6	DATE:	06/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:18 AM
MET WITH:	Marilou Rojas		TIME COMPLETED:	03:05 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 08:18 a.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. When the LPA arrived, there were six (6) residents and two (2) staff present. The LPA met with staff John Winter Del Monte and explained the reason for the visit. Shortly thereafter, administrator Marilou Rojas arrived. Interviews: The LPA initiated staff interviews at 8:20 a.m. During the visit the LPA conducted two (2) resident and two (2) staff interviews. The LPA attempted to interview a third resident, however they declined to be interviewed. At 9:00 a.m., the LPA conducted a tour of the physical plant with the administrator 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 four (4) resident bedrooms, and two (2) bathrooms. The LPA observed fire extinguishers at the facility, which were fully charged and last serviced 02/13/2024. All smoke alarms and carbon monoxide detectors were tested. LPA observed all required postings throughout the facility. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects are stored in a locked drawer and cleaning supplies are stored in a locked cabinet under the sink. Food is prepared based on the menu and changed upon resident requests. Snacks and beverages are always available for residents. Bedrooms: The LPA observed all resident bedrooms properly furnished and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. At 09:25 a.m. the LPA observed a basket on top of a side table that contain a bottle of antifungal powder, Gold Bold medicated foot powder, and personal grooming items in room #3. Upon observation, administrator stored the basket away inaccessible to the residents. 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: 06/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024

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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Document Has Been Signed on 06/15/2024 02:58 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: KINDCARE SENIOR HOME	FACILITY NUMBER: 565850269
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) 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:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as medication cabinet was left unlocked with two residents present, and there was grooming supplies and over the counter medicated foot powder in room #3 acessible to residents in care which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/15/2024
	Plan of Correction
1 2 3 4	Plan of correction has been met, medication cabinet was locked and grooming supplies and medicated foot powder was stored inaccesibe to residents in care during today's visit.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/15/2024 02:58 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: KINDCARE SENIOR HOME	FACILITY NUMBER: 565850269
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(2)(B)

Personal Accommodations and Services

(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above in one (1) of three (3) staff as interviews revealed that S1 sleeps at the facility overnight four days a week which poses a potential health and safety or personal rights risk to persons in care.
	POC Due Date: 06/21/2024
	Plan of Correction
1 2 3 4	The administrator stated the staff will no longer sleep in the living room. The administrator shall submit a signed written memo of understanding of the regulation and also written notification that the staff will no longer sleep in the living room. This shall be submitted to CCL by 06/21/24.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 2 out of 3 staff who are missing 3 hurs of medication training and missing restricted health conditions training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/21/2024
	Plan of Correction
1 2 3 4	Administrator agreed to provide proof of required training hours and subjects for staff 1 and 2 by 06/21/2024.

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: 06/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/15/2024 02:58 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: KINDCARE SENIOR HOME	FACILITY NUMBER: 565850269
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above in six out of six residents that had medications pre-poured and out of their original containers for more than 24 hours which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/21/2024
	Plan of Correction
1 2 3 4	The Administrator agrees to submit a written memo of understanding of regulation 87465 and written notification that medication will not be prepoured for more than 24 hrs to CCL by 06/21/2024.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024

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: KINDCARE SENIOR HOME	FACILITY NUMBER: 565850269
	VISIT DATE: 06/15/2024

NARRATIVE

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Bathrooms: The LPA observed all bathrooms to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene. At 09:28 a.m., water temperature in the outside restroom was measured at 106.6 degrees Fahrenheit.
Common Areas: These included the living, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There was a fireplace in the living room which was covered with furniture. There were no obstructions and/or tripping hazards throughout the facility.
The garage: The LPA observed the garage, where the emergency water is stored, and the washer and dryer are held. The garage is used to store additional cleaning supplies in locked cabinets. The garage is unlocked.
Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water on the premises.
Record Review: At 9:41 a.m., a review of facility files was initiated. Facility records are stored in a locked cabinet in the living room. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 04/14/2024). The LPA obtained Resident Roster, and Staff Roster. The LPA reviewed five (5) out of six (6) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All resident files were complete and current. The LPA reviewed three (3) out of three (3) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. Two staff (S1, S2) were missing prohibited health condition training and 3 (3) out of eight (8) hours of annual medication training. During record review, while reviewing staff schedule, Administrator and Licensee stated that S1 sleeps at the facility overnight four days a week.
Medications: A medication audit was initiated at 01:06 p.m. and the following was observed. Medications are centrally stored and locked in a locked cabinet in the living room. Current medications for all residents are recorded on the centrally stored medications and destruction records. Staff are pre-pouring medication for all residents for more than 24 hours in advance. First aid supplies were reviewed and complete. At approximately 1:46 p.m. the LPA observed medication cabinet was left unlocked in the living room with two residents in present.

Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit. Exit Interview Conducted / Appeal Rights and a copy of this report has been issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024

LIC809 (FAS) - (06/04)

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