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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800987
Report Date: 11/18/2024
Date Signed: 11/18/2024 11:51:18 AM

Document Has Been Signed on 11/18/2024 11:51 AM - 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:IRENE'S BOARD & CAREFACILITY NUMBER:
405800987
ADMINISTRATOR/
DIRECTOR:
ANGELITA O. MARAVILLASFACILITY TYPE:
740
ADDRESS:220 VIA PROMESATELEPHONE:
(805) 227-0276
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6CENSUS: 4DATE:
11/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee, Angelita Maravillas,TIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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At 9:00am on 11/18/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual facility inspection. LPA met with Licensee Angelita Maravillas, announced who he was and the reason for the visit being the annual facility inspection.

At 9;30am Licensee and LPA conducted a full physical tour of the facility. The facility has 3 double occupancy resident rooms and one shared bathroom downstairs, upstairs, which is not licensed is for staff live-in, with 3 bedrooms, and 2 bathrooms one being an on suite bathroom, all for staff. On the first floor there are two living room areas, one room serves as a visitation room and the other living room serves as the general living room for residents in care. There is a kitchen an dining room area adjacent to the main living room. There is a laundry room where chemicals are located which is locked at all time. Centrally Stored Medications are located in a locked cabinet between the main living room and dinning area. There is a full first aide kit located in this locked cabinet. LPA noted that the stove was in need of cleaning and the staff began cleaning stove and finished before LPA finished annual inspection. LPA noted that there is at least 2 days of perishable foods and at least 7 days of non perishable foods on hand in the facility for residents and staff. LPA observed emergency water supply. LPA noted that the resident bedrooms had required chair, lighting, drawers, and bedding. LPA noted that there is liquid soap and paper towels in the residents bathroom. LPA observed back porch is elevated and has seating, table, with umbrella for shade for outdoor visitation. LPA noted that no doors or exits were blocked and all free and clear of obstruction. LPA viewed two fire extinguishers in the green, working smoke detectors in all resident rooms and two working carbon monoxide detectors tested by LPA. LPA reviewed all staff and resident files and confirmed all staff are cleared to be working in facility. LPA Reviewed Emergency Evacuation plan and Infection control plan and noted that both were reviewed and singed by licensee within the past 12 months. LPA noted that facility posting were on the wall adjacent to the 3 resident rooms and advised licensee for a more obvious centrally located location for facility posting.
Continued on LIC809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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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: IRENE'S BOARD & CARE
FACILITY NUMBER: 405800987
VISIT DATE: 11/18/2024
NARRATIVE
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Licensee and LPA conducted a full review and the annual care tools modules. LPA noted that there was one violation pertaining to documentation of emergency quarterly drills. LPA noted that there were no other violations or citations as a result of the full annual care tools review. LPA issued citation for one violation during this annual inspection. LPA conducted interviews with 3 residents and 3 staff.

Exit interview, report read, appeal rights and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2024 11:51 AM - It Cannot Be Edited


Created By: Mark Jeffries On 11/18/2024 at 11:41 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: IRENE'S BOARD & CARE

FACILITY NUMBER: 405800987

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on not being able to produce evidence of quarterly drills, the licensee did not comply with the section cited above during the annual facility inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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Licensee/Administrator will conduct emergency disaster drill on each shift and show proof to LPA by 12/09/2024. via email or text picture on cell phone.
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:Kelly Burley
LICENSING EVALUATOR NAME:Mark Jeffries
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


LIC809 (FAS) - (06/04)
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