567609649-10-25-2023-29-AS-TCAA-CWXVCN-20231025161924

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609649
Report Date: 10/25/2023
Date Signed: 10/25/2023 04:21:21 PM

Document Has Been Signed on 10/25/2023 04:21 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:	MOM AND DAD HOME CARE		FACILITY NUMBER:	567609649
ADMINISTRATOR:	ARLENE MARTINEZ		FACILITY TYPE:	740
ADDRESS:	743 SARA DR		TELEPHONE:	(805) 351-9079
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY:	6	CENSUS: 4	DATE:	10/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Arlene Martinez		TIME COMPLETED:	04:37 PM

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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with Administrator Arlene Martinez and explained the reason for the inspection. When the LPA arrived there were two staff and four residents present. There is currently one resident receiving hospice care services.

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: LPA inspected the kitchen. Knives and cleaning supplies are stored inaccessible in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food and food was stored at appropriate temperatures.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detectors and carbon monoxide detector were tested and were operational at the time of the visit. The fire extinguisher was last serviced 5/22/2023. The LPA observed required postings throughout the common space. No bodies of water noted. The facility has one common restroom and one private restroom for residents' use. Restrooms were observed to be clean and sanitary with hand soap and paper towels. The washer and dryer are in the hallway in a locked closet. There is water and additional food located in the garage. Infection control practices were discussed. The facility has a sufficient supply of Personal Protective Equipment (PPE).

Report continued on LIC 809-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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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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: MOM AND DAD HOME CARE	FACILITY NUMBER: 567609649
	VISIT DATE: 10/25/2023

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continued from LIC 809

BEDROOMS: The four resident bedrooms were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. This facility has a staff room adjacent to the kitchen.

MEDICATIONS: Medications are locked and centrally stored in a closet in the hall. LPA reviewed medications which appear to be given as prescribed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record.

RECORDS: LPA reviewed the records for four clients and two staff. Resident and staff files reviewed were found to be complete. The Administrator's certificate expires in October 2024. Disaster drills are conducted quarterly, of which the last drill was conducted on July 2023, however the administrator could not locate the documentation showing when the drill occurred. LPA interviewed one staff and attempted to interview a resident; no concerns were noted.

No deficiencies were observed during the inspection. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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