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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609799
Report Date: 05/18/2024
Date Signed: 05/18/2024 06:03:17 PM

Document Has Been Signed on 05/18/2024 06:03 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:CONNIE'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
567609799
ADMINISTRATOR/
DIRECTOR:		FLORO CORTESFACILITY TYPE:
735
ADDRESS:614 E NECTARINE STTELEPHONE:
(805) 240-2188
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 4DATE:
05/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Nicole CortesTIME VISIT/
INSPECTION COMPLETED:
06:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required -1 Year inspection. The LPA arrived at 1:05 PM and met with staff and explained the reason for today's inspection. When the LPA arrived, there was one staff and four clients present. The home is vendored by Tri-Counties Regional Center as a level 2 home. Administrator Nicole 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.

Restrooms: 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. At approximately around 1:25 PM during the physical tour, the LPA observed staff #1 (S1) opening the door connected from the private restroom to client #1’s (C1) room door without knocking, infringing on C1’s privacy. C1 was not clothed. At 1:28 PM the LPA observed shared hand towels in the client’s common hallway restroom. Upon observation staff stated, the clients use them to dry their hands due to clients throwing away paper towels in the toilet causing it to clog. Napkins were placed in the restrooms during the visit. At 01:34 PM the hot water temperature was tested in the common hallway restroom and measured at 101.1 degrees F.

Report will continue on LIC-809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
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: CONNIE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 567609799
VISIT DATE: 05/18/2024
NARRATIVE
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Common Areas: The living and dining room were furnished appropriately. Infection control signs are posted throughout the facility. Facility has a supply of PPE. The two fire extinguishers were fully charged and last serviced on 10/24/2023. The carbon monoxide detectors and smoke alarms in the common areas and bedrooms were tested and were found to be operational. The backyard has seating for client use with a shaded area.

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

Interviews: The LPA conducted two (2) client and one (1) staff interviews. During staff interview, staff stated that they hide one of the client's medication due to them refusing to take it. Staff stated Psychiatrist is aware, and instructed them to hide the medication, however no doctors order was provided.

Records: Facility records were reviewed at 02:32 PM. Disaster drills are being conducted monthly, (last drill conducted on 05/01/2024). Four (4) client records were reviewed for, but not limited to: care plans, medical records, admissions agreement, consent forms. One out of five clients did not have a medical assessment on file. Upon observation, the administrator stated that the client has a medical assessment and the co-administrator had it and would provide to the LPA. Files reviewed were otherwise complete.

Five personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and other appropriate training. Files reviewed were complete.

Medications: A medication audit was initiated at 4:19 PM and the following was observed. The medications were stored in a locked cabinet in the kitchen inaccessible to the clients. During Client #2 (C#2's) audit the LPA observed B-Complex and L-Methyl folate 5mg not documented on the centrally stored medication and destruction record (CSMDR). Upon observation staff stated C2’s mother sent the medication for the client, and the Psychiatrist was aware. Staff and administrator were not able to provide a physician’s order for the medication



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 Nicole Cortes. Appeal Rights and a copy of this report has been issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 05/18/2024 06:03 PM - It Cannot Be Edited


Created By: Esther Cortez On 05/18/2024 at 04:59 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: CONNIE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 567609799

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in two (2) of two (2) medications that did not have a presciption order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2024
Plan of Correction
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Administrator agrees to stop medication immidiately until doctors order is obtained, and will submit a written statement of understanding acknowledging 80075 by 05/21/2024.
Type A
Section Cited
CCR
80075(b)(3)

80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (3) Assistance with self-administration does not include forcing a client to take medications, hiding or camouflaging medications in other substances without the client's knowledge and consent, or otherwise infringing upon a client's right to refuse to take a medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in 1/4 clients, as staff stated they hide a clients medication in their drink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2024
Plan of Correction
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Administrator agrees to stop comouflaging medications and submit a written statement of understanding ackowleding 80075 in its entirety and conduct medication training with all staff, and submit proof to CCL by 5/21/2024.
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: 05/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/18/2024 06:03 PM - It Cannot Be Edited


Created By: Esther Cortez On 05/18/2024 at 04:59 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: CONNIE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 567609799

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2024

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 and interview, the licensee did not comply with the section cited above in one of two restrooms that had common washcloths for client use which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2024
Plan of Correction
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Plan of correction has been met, administrator placed napkins in the restroom.
Type B
Section Cited
CCR
80088(e)(1)
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:

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 in one of two restrooms where the water temperature measured at 101.1 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2024
Plan of Correction
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Administrator agrees to adjust water temperature and submit a 5 day water log of temperature in the restroom within the required water temperature of 105-120 degrees F.
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: 05/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 05/18/2024 06:03 PM - It Cannot Be Edited


Created By: Esther Cortez On 05/18/2024 at 05:50 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: CONNIE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 567609799

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(1)
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons.

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 in one of four clients, when staff opened clients bedroom door without knocking, and client was not clothed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2024
Plan of Correction
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Administrator agrees to conduct a staff training on personal rights and submit proof by 05/27/2024.
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:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024


LIC809 (FAS) - (06/04)
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