565850322-1-11-2024-29-AS-ECOZ-CZE3BG-20240111170620

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850322
Report Date: 01/11/2024
Date Signed: 01/11/2024 05:06:52 PM

Document Has Been Signed on 01/11/2024 05:06 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ARTHUR FAMILY HOMES II		FACILITY NUMBER:	565850322
ADMINISTRATOR:	ARTHUR, AKOSUA		FACILITY TYPE:	735
ADDRESS:	3611 TERRACE DRIVE		TELEPHONE:	(805) 248-8099
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 4		CENSUS: 3	DATE:	01/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Akosua Arthur		TIME COMPLETED:	05:15 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) Esther Cortez conducted an unannounced Required - 1 Year Annual inspection at the facility today. Administrator Akosua Arthur arrived shortly after the inspection began. The home is vendored by Tri-Counties Regional Center as a level II home. At 1:44 p.m. the LPA toured the physical plant areas with the Administrator inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double-story residence that consists of four (4) client bedrooms, one (1) staff room, and three (3) bathrooms. The LPA observed fire extinguishers at the facility, which were fully charged and last serviced 01/8/2024. All smoke alarms and carbon monoxide detectors were tested and functioned properly. LPA observed all required postings in the living room. KITCHEN: Knives and cleaning supplies are stored in locked cabinets. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The LPA observed four single client bedrooms and one staff bedroom. Client rooms were furnished appropriately with sufficient lighting. The LPA observed client room #1 without a window screen, and client room #3 without a window screen, and the glass window not properly installed . Upon observation the Administrator installed window screen in room #1. RESTROOMS: There are two common restrooms for client use which were clean and sanitary and in operating condition with hand soap, paper towels, and toilet paper. At 01:58 p.m., water temperature in the client’s restroom was measured at 115.0 degrees Fahrenheit. COMMON SPACES: These included the living rooms, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the second living room, which is covered with a glass screen. The facility maintained a comfortable temperature of 74 degrees. There were no obstructions and/or tripping hazards throughout the facility. Report will continue on LIC809-C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARTHUR FAMILY HOMES II	FACILITY NUMBER: 565850322
	VISIT DATE: 01/11/2024

NARRATIVE

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The garage/laundry: The LPA observed the laundry room, where the washer and dryer are held, and the garage where the emergency food and water is stored. The garage and laundry rooms are not locked. Cleaning supplies and disinfectants are kept in a locked closet.

Record Review: At 02:20 p.m., a review of facility files was initiated. Facility records are stored in a locked cabinet in the first living room. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 01/07/2024). The LPA obtained Client Roster, Staff Roster, and facility Sketch. The LPA reviewed five (5) of five (5) staff Files. The LPA could not verify the Administrators current HIV /TB training (minimum 4 hours). The LPA reviewed three (3) out of three (3) client files. All documents reviewed appeared complete and current.

Medications: At 4:09 p.m. a medications review was initiated. Medications are centrally stored and locked in a cabinet in the living room; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Interviews: During the visit the LPA conducted two (2) client, and two (2) staff interviews. No immediate concerns voiced at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 01/11/2024 05:06 PM - It Cannot Be Edited

Created By: Esther Cortez On 01/11/2024 at 04:42 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: ARTHUR FAMILY HOMES II	FACILITY NUMBER: 565850322
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. 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 LPA observed two rooms without window screens and one of the two rooms window was also not properly installed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Upon observation Administrator installed screen in room #1 and agreed window screen and glass window in room #3 will be repaired/replaced by 1/12/24. Once completed administrator will submit photos to ensure all the above is cleaned and in good repair.

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

LICENSING EVALUATOR NAME:

Esther Cortez

LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

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