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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609799
Report Date: 04/21/2023
Date Signed: 04/21/2023 03:23:24 PM

Document Has Been Signed on 04/21/2023 03:23 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:CONNIE'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
567609799
ADMINISTRATOR:FLORO CORTESFACILITY TYPE:
735
ADDRESS:614 E NECTARINE STTELEPHONE:
(805) 240-2188
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
04/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Nicole Cortes/Floro CortesTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required -1 Year inspection. The LPA arrived at 9:53 and met with staff Nicole Cortes and explained the reason for today's inspection. When the LPA arrived there was one staff and three clients present. The home is vendored by Tri-Counties Regional Center as a level 2 home. Administrator Floro Cortes arrived during the inspection.

The LPA, along with the staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with the Health and Safety Code and Title 22 Regulations.

Kitchen The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Emergency water and food is stored in the garage. Cleaning supplies, sharp items, and medications are stored in locked cabinets.

Common Areas: The living and dining room were furnished appropriately. Infection control signs are posted through out the facility. Facility has a supply of PPE. The two fire extinguishers were fully charged and last serviced on 10/10/2022. The facility has one common and one private restroom for client use. Restrooms were observed to be clean and sanitary with hand soap and toilet paper. Although, shared hand towels are currently being used for drying the client's hands. Napkins were placed in the restrooms during the visit. At 10:12 AM the hot water temperature was tested in the common hallway restroom and measured at 106.5 degrees F. The carbon monoxide detectors and smoke alarms in the common areas and bedrooms were tested at 10:16 AM and were found to be operational. The backyard has seating for client use but there is no shaded area for the clients. No open bodies of water were observed.

Bedrooms: The LPA observed the four client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2023
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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Document Has Been Signed on 04/21/2023 03:23 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 04/21/2023 at 11:54 AM
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: CONNIE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 567609799

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)(B)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths. (B) The use of common towels and washcloths shall be prohibited.

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 the use of common towels is being using for drying hands in the restroom which poses a potential health rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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The towels were removed during the inspection and replaced with napkins. Plan of correction is cleared.
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

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 there is no shaded outside area for client use which poses a potential health and personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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The Licensee shall submit proof of a shaded area for client use by 05/05/2023.
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
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023


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Document Has Been Signed on 04/21/2023 03:23 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 04/21/2023 at 11:54 AM
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: CONNIE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 567609799

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as the Administrator does not have a current Administrator certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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The Administrator states he is in the process of completing classes to renew the certificate. The Administrator shall submit proof by 05/05/2023 that he has completed the courses and mailed the renewal request by 05/05/2023.
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one (Client #1) of five client files reviewed did not have a medical assessment on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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The Administrator shall submit proof Client #1 has a medical assessment on file by 05/05/2023.
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
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023


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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: CONNIE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 567609799
VISIT DATE: 04/21/2023
NARRATIVE
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MEDICATIONS: Medications are locked and centrally stored in the kitchen room. At 10:16 AM medications for three clients were reviewed. 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. No errors were observed during the medication review. The first aid kit was observed to be complete.

RECORDS: Facility records were reviewed at 10:47 AM. Disaster drills are being conducted monthly. Five client records were reviewed for, but not limited to: care plans, medical records, admissions agreement, consent forms. One out of five clients (Client #1) did not have a medical assessment on file. Files reviewed were otherwise complete.

Four personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and other appropriate training. Administrator Floro Cortes does not have a current Administrator Certificate (Expired 11/05/2022). Files reviewed were otherwise complete. Staff interview conducted. LPA was unable to interview any clients during the inspection.

Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 1 & 6, the following deficiencies were observed and cited during the visit. (See 809-D.) Exit Interview conducted and the report was reviewed with the Floro Cortes. Appeal Rights and a copy of this report has been issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
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