565850274-5-3-2023-29-AS-DPEA-CU2TZ7-20230724150949

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850274
Report Date: 05/03/2023
Date Signed: 05/03/2023 12:11:43 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/27/2023 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20230427144838

FACILITY NAME:	PETIT OASIS		FACILITY NUMBER:	565850274
ADMINISTRATOR:	VINCECRUZ, SUSAN		FACILITY TYPE:	740
ADDRESS:	2802 PETIT STREET		TELEPHONE:	(805) 383-8894
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY:	6	CENSUS: 4	DATE:	05/03/2023
		UNANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	Roberto Evangeline		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Centrally stored medications are accessible to residents in care
Cleaning solutions and other dangerous items are accessible to residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegations listed above. LPA arrived at the facility at 10:06AM and met with facility staff Fernando Villanueva. Administrator was contacted via telephone and Licensee Roberto Evangeline arrived at 10:23AM. Entrance interview conducted.

During today's visit, LPA interviewed Licensee at 10:25AM, and toured the facility with Licensee at 10:53AM. The following was then determined:

Upon arrival at the facility, LPA observed Windex cleaner and Clorox disinfecting wipes in the dining room, assessible to residents in care. Staff was using the Windex to clean the windows and subsequently moved the Windex cleaner, however, the Clorox wipes were not moved and/or locked at that time. Additionally, LPA observed staff enter the kitchen and lock the medication cabinet after the LPA had arrived at the facility.
Report Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230427144838

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PETIT OASIS	FACILITY NUMBER: 565850274
	VISIT DATE: 05/03/2023

NARRATIVE

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During the facility tour, at 10:54AM, LPA observed the cabinet under the common resident restroom sink was unlocked, which contained personal care and grooming items as well as cleaning supplies. At 10:58AM, LPA observed medications stored in the refrigerator in an unlocked box, rendering them accessible to residents in care. Based on observation, the allegations that "Centrally stored medications are accessible to residents in care" and "Cleaning solutions and other dangerous items are accessible to residents in care" are deemed SUBSTANTIATED at this time.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies 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: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230427144838

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PETIT OASIS	FACILITY NUMBER: 565850274
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/03/2023 Section Cited CCR 87309(a)	1 2 3 4 5 6 7	87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	During today's visit, Licensee ensured the cleaning items were locked. POC cleared.
	8 9 10 11 12 13 14	Based on observation, the licensee did not comply with the above cited section, as Clorox wipes were on the dining table and cleaning supplies were observed in the resident restroom, which poses an immediate safety risk to residents in care.	8 9 10 11 12 13 14
Type A 05/04/2023 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (h) (2) Centrally stored medicines 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:	1 2 3 4 5 6 7	Licensee stated they will obtain a lock for the box of medications that are stored in the refrigerator and ensure all other medications remain locked. Proof of locked medications will be sent to CCL by POC due date.
	8 9 10 11 12 13 14	Based on observation, the licensee did not comply with the above cited section, as medications were observed in an unlocked box inside the refrigerator, which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14

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: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC9099 (FAS) - (06/04)

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