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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610034
Report Date: 07/21/2023
Date Signed: 09/22/2023 02:32:13 PM

Document Has Been Signed on 09/22/2023 02:32 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SAN MARCOS CGS., INC.FACILITY NUMBER:
567610034
ADMINISTRATOR:GALLARDO-MAGANA, CAROLINAFACILITY TYPE:
735
ADDRESS:130 CARLISLE CT.TELEPHONE:
(805) 612-4925
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 4CENSUS: 4DATE:
07/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Co Administrator Lailani MacasiasTIME COMPLETED:
04:45 PM
NARRATIVE
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This is an amended report to rescind the civil penalty issued from Civil Penalty Assessment-Immiediate $500 and Repeat violations LIC421IM on 7/21/2023 and issue the correct Civil Penalty Assessment- Caregiver background check LIC421BG $500 civil penalty.

At 08:15 a.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. When the LPA arrived, there were one (1) staff and two (2) clients present. The clients left to day program shortly after the LPA arrived. The LPA was greeted by staff and informed them of the reason for the visit. Co-Administrator Lailani Macasias arrived shortly after

At 08:35 a.m., the LPA conducted a tour of the physical plant with administrator Lailani to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of three (3) resident bedrooms, one (1) office, one (1) medication room, and two (2) bathrooms. The home is vendored by Tri-Counties Regional Center as a level 4-G home. The LPA observed three (3) fire extinguishers at the facility, which were fully charged and last serviced 01/13/2023. At 09:10 a.m., all smoke alarms and carbon monoxide detectors were tested. The smoke detector in the living room was observed to not be working. Upon observation the administrator had staff installed a new smoke detector during the visit. LPA observed all required postings.
Kitchen: During the facility tour at 08:40 a.m., the kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects are stored in a locked box and cleaning supplies are stored in locked cabinets. Food is prepared based on the menu and modified as needed for individual clients. Snacks and beverages are always available for clients.Bedrooms: The LPA observed all resident bedrooms properly furnished with at least one chair, night-stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Report will continue on 809-C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2023
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 07/21/2023 04:42 PM - It Cannot Be Edited


Created By: Esther Cortez On 07/21/2023 at 03:47 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: SAN MARCOS CGS., INC.
FACILITY NUMBER: 567610034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

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 smoke detector in the living room was observered to not be working during the time of the inspection which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Upon observation, the administrator had staff install a new smoke detector during the visit.
In accordance with the California Health and Safety Code Section 1568.0822(c), you are hereby notified that an immediate $500 civil penalty per violation, followed by $150 per day per violation will be assessed until corrected
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

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 as one (S1) out of eleven staff is not associated to the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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The administrator agrees to associate staff immidiately and S1 will not return to the facility until they are associated. The administrator will provide a new schedule without S1 to CCL by 7/21/2023 and proof of S1 associated to the facility.
In accordance with the California Health and Safety Code Section 1568.0822(c), you are hereby notified that an immediate $500 civil penalty per violation, followed by $150 per day per violation will be assessed until corrected
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:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/21/2023 04:42 PM - It Cannot Be Edited


Created By: Esther Cortez On 07/21/2023 at 03:47 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: SAN MARCOS CGS., INC.
FACILITY NUMBER: 567610034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(C)
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: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

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 as PRN medication Ibuprofen given to client #1 was not recorded. No date and time the PRN prescription was taken, the dosage taken, and the client's response which poses a potential health and safety risk to persons in care.
POC Due Date: 08/03/2023
Plan of Correction
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Administrator stated that she will insure that all Staff is retrained on documenting medication correctly, and will review and audit all clients medications to make sure they are being correctly documented and given.
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:Desaree Perera
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


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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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAN MARCOS CGS., INC.
FACILITY NUMBER: 567610034
VISIT DATE: 07/21/2023
NARRATIVE
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Bathrooms: The LPA observed the resident’s bathroom to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene. At 12:08 p.m., water temperature in the resident’s restroom was measured at 106.4 degrees Fahrenheit.

Common Areas: These included the living, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the living room, which is covered with a screen. The facility maintained a comfortable temperature of 70 degrees. There were no obstructions and/or tripping hazards throughout the facility.



The garage: The LPA observed the garage, where the washer and dryer are held, and the emergency food and water is stored. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. The garage is not locked.

Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises.

Infection Control: There was a central entry point for symptom screening and temperature checks. Facility has a sufficient supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol was sufficient. The facility's procedures as it pertains to infection control are adequate.

Record Review: At 9:15 a.m., a review of facility files was initiated. Facility records are stored in the locked office. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 05/31/2023). The LPA obtained Client Roster, and Staff Roster. At 10:45 a.m., the LPA reviewed five (5) of eleven (11) staff Files and four (4) of four (4) client files. All documents reviewed appeared complete and current.

Interviews: During the visit the LPA conducted one (1) client, and two (2) staff interviews. No immediate concerns voiced at this time.



Report wil continue on 809-C.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAN MARCOS CGS., INC.
FACILITY NUMBER: 567610034
VISIT DATE: 07/21/2023
NARRATIVE
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Medications: A medication audit for two (2) of four (4) clients was initiated at 1:00 p.m. and the following was observed. The medications were stored in the medication room, in a locked locker and inaccessible to the clients. During Client #1 (C#1's) audit, the LPA observed Ibuprofen not properly documented on the centrally stored medication and destruction log, as the quantity was not documented. After Staff and the LPA counted the pills, the quantity remaining did not matched with the number of times C1 had been given their medication logged on the Medication Administration Record (MAR). Seven (7) Ibuprofen pills were unaccounted for. During C#2's audit, Ibuprofen was not properly documented on the centrally stored medication and destruction log, as the quantity did not matched the prescription label. The LPA observed Inconsistent documentation of the quantity and strength of the PRN medications for both C1 and C2 on the logs.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): A civil penalty was issued.

Exit interview conducted and copy of the report and appeal rights provided to administrator Lailani Macasias.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC809 (FAS) - (06/04)
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