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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609650
Report Date: 07/31/2024
Date Signed: 07/31/2024 03:32:26 PM

Document Has Been Signed on 07/31/2024 03:32 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:CLARKS RESIDENTIAL CARE HOME LLCFACILITY NUMBER:
567609650
ADMINISTRATOR/
DIRECTOR:		CARINO II, RICHARD TFACILITY TYPE:
735
ADDRESS:4525 READING DRTELEPHONE:
(805) 246-8446
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 4CENSUS: 4DATE:
07/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:48 AM
MET WITH:Martin CarinoTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:48 AM. LPA met with facility staff who contacted administrator Charles “Martin” Carino via telephone. Administrator arrived at 10:00 AM. LPA explained the reason for today's visit. Entrance interview conducted.

The facility is vendored through Tri-Counties Regional Center as a level 4 home.

Beginning at 09:52 AM, the LPA, along with facility administrator, toured the physical plant areas 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 observed:

The hardwired carbon monoxide and smoke alarms were tested at 09:54 AM and all functioned properly. The fire extinguisher was observed to be fully charged and last serviced on 12/13/2023.

KITCHEN: Knives are stored in a locked drawer. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medications were observed to be in a locked cabinet located within the kitchen.

BEDROOMS: The LPA observed four single-occupancy client bedrooms, all of which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: Restrooms are clean and sanitary and in operating condition. Hot water was checked in the private resident restroom and measured at 105.8 degrees Fahrenheit. Water temperature was checked in the common restroom and was measured at 105.6 degrees Fahrenheit. Both were measured within the required range. Showers were observed to contain non-slip surfaces and mats.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
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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Document Has Been Signed on 07/31/2024 03:32 PM - It Cannot Be Edited


Created By: Trevor Byrne On 07/31/2024 at 12:10 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: CLARKS RESIDENTIAL CARE HOME LLC
FACILITY NUMBER: 567609650

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as gardening shears were observed to be unsecured on a table in the backyard which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Facility staff removed the shears and secured them making them inaccessable to clients in care at the time of the visit. Staff will be conducting an all hands meeting to stress the importance of securing dangerous objects. POC is cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024


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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: CLARKS RESIDENTIAL CARE HOME LLC
FACILITY NUMBER: 567609650
VISIT DATE: 07/31/2024
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COMMON SPACES: Living room, tv room, and dining room furniture was observed to be in good condition. The LPA observed all required postings upon entry. Games are available for resident use located in the TV room. A properly screened fireplace was observed in the dining room.

OUTDOORS: LPA toured outdoor areas. Tables and chairs were observed with appropriate shading. A shed was observed to be locked. The facility has an emergency exit gate that was free from obstruction. At 10:12 AM unsecured gardening shears were observed on a table outside. Facility staff immediately stored and secured the shears making them inaccessible to clients in care.

GARAGE: Garage was observed to be utilized as an activity space for clients. The garage contained laundry areas with locked chemical storage. The garage contained adequate emergency food and water supplies.

CLIENT FILES/CASH RESOURCES: LPA reviewed all 4 (four) client files for, but not limited to: physician's report, proof of TB test, Admission Agreement, and cash resources. All 4 (four) of 4 (four) client files reviewed were complete and contained all documentation required. Cash resources were reviewed, and no discrepancies were noted.

MEDICATION REVIEW: Beginning at 11:02AM, LPA reviewed medications for 2 (two) clients. All medications reviewed were documented and stored in compliance with regulation.

STAFF FILES: LPA reviewed files for 6 (six) staff members. All staff files contained all required documents. Staff training, including 1st aid / CPR, was up to date.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: LPA reviewed the facility’s emergency disaster plan and infection control plan. The facility’s emergency disaster plan is adequate and reviewed annually. The last emergency disaster drill was conducted on 07/05/2024. The facility’s practices as it pertains to infection control are adequate.

INTERVIEWS: During today's visit, LPA attempted to interview 2 (two) clients, both of which were nonverbal and unable to complete the interviews. LPA interviewed 2 (two) staff members. Both staff understood their roles, clients rights, and the forms of abuse as well as the proper reporting procedures.

During today's visit LPA obtained a copy of the facility's surety bond and staff roster. Report Continued on LIC 809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CLARKS RESIDENTIAL CARE HOME LLC
FACILITY NUMBER: 567609650
VISIT DATE: 07/31/2024
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The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Licensee was advised that failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC809 (FAS) - (06/04)
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