567609649-11-4-2024-29-AS-ECOZ-DAQ37G-20241104165955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609649
Report Date: 11/04/2024
Date Signed: 11/04/2024 05:00:05 PM

Document Has Been Signed on 11/04/2024 05:00 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/ DIRECTOR:	ARLENE MARTINEZ		FACILITY TYPE:	740
ADDRESS:	743 SARA DR		TELEPHONE:	(805) 351-9079
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:10 PM
MET WITH:	Arlene Martinez		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with staff and explained the reason for the inspection. When the LPA arrived there were two staff and six residents present. Administrator Arlene Martinez arrived shortly after.

RECORDS: At 2:20 PM the LPA initiated record review. Facility records are stored in a locked medication closet. The LPA observed documentation of Infection Control, Disaster prevention, Emergency and Disaster Plan and last Disaster drill (conducted on 09/05/2024). The LPA obtained Client Roster, and Staff Roster. The LPA reviewed five (5) out of six (6) resident files and five (5) out of eight (8) staff files. The following was observed: Three (3) residents did not have the Consent for Emergency Medical Treatment form LIC627C on file, and one staff (S1) did not have a personnel record on file, otherwise all files were complete and current.

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.

At 4:10 p.m. the LPA toured the physical plant areas inside and outside, with staff 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.

Report will continue on LIC809-C, 2nd page.

Kasandra Lopez	TELEPHONE: (818) 596-4343
Esther Cortez	TELEPHONE: (747) 230-2225
	DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024

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: MOM AND DAD HOME CARE	FACILITY NUMBER: 567609649
	VISIT DATE: 11/04/2024

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

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 facility has a fire extinguisher, fully charged and with the last purchased date of 5/16/2024. The LPA observed required postings throughout the common space. No bodies of water noted. The LPA observed cracks in the dining room floor, upon observation, the Administrator stated they already have plans to install new flooring after Thanks Giving Holiday.

RESTROOM: 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 hot water in the common resident restroom measured at 110.7* F. 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).

INTERVIEWS: The LPA conducted three (3) resident and two (2) staff interviews. No concerns were voiced.

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

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024

LIC809 (FAS) - (06/04)

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