565850274-8-12-2024-29-AS-MARO-D83T24-20240812142008

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850274
Report Date: 08/12/2024
Date Signed: 08/12/2024 02:20:17 PM

Document Has Been Signed on 08/12/2024 02:20 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:	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: 2	DATE:	08/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Roberto Ramirez		TIME COMPLETED:	02:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today. Upon arrival, there was (1) staff and two (2) residents present. LPA met with staff and the reason for the visit was explained. The Licensee Representative, Roberto Ramirez arrived at 11:00 a.m. Entrance interview conducted.

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.

KITCHEN: The LPA inspected the kitchen/food service area at 11:30 a.m. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Cleaning supplies were observed locked and inaccessible under the kitchen sink. The kitchen faucet was measured for hot water temperature, and it measured 119.3 degrees Fahrenheit at 11:35 a.m.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were observed newly purchased on 04/14/2024. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 08/02/2024. Activities were observed in the common areas. LPA observed working telephone on premises.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

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

FACILITY NAME: PETIT OASIS	FACILITY NUMBER: 565850274
	VISIT DATE: 08/12/2024

NARRATIVE

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Report Continued from LIC 809...

RESTROOMS: The two (2) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the first bathroom measured at 115.5 degrees Fahrenheit at 11:21 a.m.; and the second bathroom measured at 116.7 degrees Fahrenheit at 11:25 a.m.

BEDROOMS: There are three (3) total bedrooms in the facility; all bedrooms are approved for double occupancy. Resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting.

GARAGE/BACKYARD: The garage was observed and locked at the time of the visit. There is a washer and dryer on premises. Laundry detergent was observed locked and inaccessible. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. There is a pool on premises which was locked and inaccessible at the time of the visit.

RECORDS: LPA reviewed Resident Records at 11:55 a.m. and Personnel Records at 12:22 p.m.

Two (2) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. One (1) out of two (2) residents did not have a completed preplacement appraisal on file. Licensee Representative completed at the time of the visit.

Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Although the facility had a designate training binder, LPA was unable to determine the number of hours completed per regulation for the past 12 months.

During today’s visit, the LPA conducted interviews with one (1) staff and two (2) residents.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

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

FACILITY NAME: PETIT OASIS	FACILITY NUMBER: 565850274
	VISIT DATE: 08/12/2024

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Report Continued from LIC 809C...

MEDICATIONS: Medications review began at approximately 1:10 p.m. The medications are locked in a cabinet adjacent to the kitchen. Medications are labeled and checked for expiration dates.

At 1:25 p.m., medication review revealed that two (2) out of two (2) residents have an over-the-counter medicine that is being administered; senna-s 50mg, and complete multivitamin for seniors 50+. however, the facility does not have the doctor’s order on file.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and 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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/12/2024 02:20 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: PETIT OASIS	FACILITY NUMBER: 565850274
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 as training binder has not been updated and LPA is unable to determine hours completed by staff, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/30/2024
	Plan of Correction
1 2 3 4	The Licensee Representative will conduct and update all staff training and submit proof to CCL on or before POC due date.

Type B

Section Cited

CCR

87465(e)

Incidental Medical and Dental Care Services

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and LPA observation, the licensee did not comply with the section cited above as 2 out of 2 residents are taking over-the-counter medications without having doctors orders on file, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/30/2024
	Plan of Correction
1 2 3 4	The Licensee Representative will obtain doctor's orders for over-the-counter medications and submit proof to CCL on or before POC due 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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC809 (FAS) - (06/04)

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