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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610034
Report Date: 07/10/2024
Date Signed: 07/10/2024 06:52:35 PM

Document Has Been Signed on 07/10/2024 06:52 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:SAN MARCOS CGS., INC.FACILITY NUMBER:
567610034
ADMINISTRATOR/
DIRECTOR:		GALLARDO-MAGANA, CAROLINAFACILITY TYPE:
735
ADDRESS:130 CARLISLE CT.TELEPHONE:
(805) 612-4925
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 4CENSUS: 4DATE:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Carolina Gallardo-MaganaTIME VISIT/
INSPECTION COMPLETED:
06:55 PM
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At 01:30 p.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. When the LPA arrived, there were no staff or clients present. The LPA contacted administrator Carolina Gallardo-Magana and informed them of the visit and the reason for the visit. Administrator arrived at approximately at 1:45 p.m.

At 02:04 p.m., the LPA conducted a tour of the physical plant with the administrator 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) client 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 06/08/2024. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings.

Kitchen: 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 client. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. The LPA observed that client#1 (C1) is non-ambulatory per their physicians report dated 07/18/23 and is in an ambulatory room. It was also observed in bedroom #3, a dividing partition was constructed without notification to CCL.

Report will continue on LIC809-C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
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 5
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: SAN MARCOS CGS., INC.
FACILITY NUMBER: 567610034
VISIT DATE: 07/10/2024
NARRATIVE
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Bathrooms: The LPA observed the client’s bathroom to be clean, and properly supplied. Clients have sufficient supplies for personal hygiene. At 2:09 p.m., water temperature in the client’s restroom was measured at 118.2 degrees Fahrenheit.
Common Areas: These included the living, dining area, and backyard. 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 73 degrees. There were no obstructions and/or tripping hazards throughout the facility. The LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water on the premises.
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.
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 2:25 p.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 05/01/2024). The LPA obtained Client Roster, and Staff Roster. 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. All P&I money and records were reviewed. Cash resources were separate and intact, and not be commingled with facility funds or petty cash.
Interviews: During the visit the LPA conducted two (2) client, and two (2) staff interviews. No immediate concerns voiced at this time.

Medications: A medication audit for two (2) of four (4) clients was initiated at 4:45 p.m. The medications were stored in the medication room, in a locked locker and inaccessible to the clients. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.

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 the Administrator.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 07/10/2024 06:52 PM - It Cannot Be Edited


Created By: Esther Cortez On 07/10/2024 at 05:56 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: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(b)(1)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients. (1) Clients whose condition becomes nonambulatory shall not use rooms or areas restricted to ambulatory clients.

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 1 out of 4 clients, as C1 is non-ambulatory per their physicians report and are living in an ambulatory room which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
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C1 needs to be placed in an non-ambulatory room. The licensee/administrator shall submit a plan to CCL and LPM Lopez by 07/11/2024 on how they will be in compliance with the regulation. This is a zero tolerance violation and civil penalties in the amount of $500 is being assessed.
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: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/10/2024 06:52 PM - It Cannot Be Edited


Created By: Esther Cortez On 07/10/2024 at 06:07 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: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)
80086(a)Alterations to Existing Building or New Facilities. Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change. .

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 1 of 3 client bedrooms as bedroom #3 was observed with a partisian which poses a potential health and safety risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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Administrator agrees they will submit a request in writing to CCL for the alteration and a new facility sketch, and will contact fire marshall to ensure the partisian is within the fire clearance.
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: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024


LIC809 (FAS) - (06/04)
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