Oasis Women’s Recovering Community

Published
0.000
Contact Information
Licensee Name
Oasis Women's Recovering Community
13832 Polk Street, Sylmar, CA 91342
Facility Name
Identification Number
190155BN
Reviews & Findings
Dates of Review
May 2 and May 3, 2016
Type of Review
COMPLIANCE REVIEW
Deficiencies

1) Title 9, Section 10564(e)(1) Personnel Requirements Class B

The above sections states, in part, ”All personnel shall be in good health. Good physical health shall be verified by a health screening, including a test for tuberculosis, performed under licensed medical supervision not more than sixty (60) days prior to or seven (7) days after employment with tuberculosis testing renewable every year.

The licensee was deficient in meeting this regulation because TB Tests for employees #1, #2, #3, and #4 were expired.

2) Title 9, Section 10564(k) Personnel Requirements Class C

The above sections states, “The licensee shall develop, maintain, and implement an ongoing training program for all staff in the areas identified in section 10564 (b)(3) of this sub chapter in addition to specific training related to their duties. Staff participation in the training program shall be documented and maintained on file for three {3) years.”

The licensee was deficient in meeting this regulation because verification of training for employees number #2; #3 and #5 were not available.

3) Title 9, Section 10565(a)(3) Personnel Records Class C

The above section states, in part, “Personnel records shall be completed and maintained for each employee, shall be available to the department for review, and shall contain date of employment.”

The licensee was deficient in meeting this regulation because employees employment date on file.

4) Title 9, Section 10569(a)(5) Personal Rights Class C

The above section states, in part, “Each resident shall have personal rights which include the address of the department.”

The licensee was deficient in meeting this regulation because the personal rights information for clients #1, #2, #3, #4 and #5 did not contain the correct address for the Department.

5) Title 9, Section 10572 (b) Health-Related Services Class B

The above section states, “During the provision of alcoholism or drug abuse recovery or treatment services as defined in section 10501(a) of this sub chapter there shall be at least one person in the facility who is capable of providing cardiopulmonary resuscitation and first aid, notwithstanding section 10572(b)(1) of this sub chapter. Individuals providing cardiopulmonary resuscitation and first aid shall be qualified by the American Red Cross or other recognized agencies.”

The licensee was deficient in meeting this regulation because the cardiopulmonary resuscitation and first aid certifications for employees #2, #3, and #5 were expired.

6) Title 9, Section 10572 (f) Health-Related Services Class B

The above sections states, in part, “Licit medications which are permitted by the licensee shall be controlled as specified by the licensee’s written goals, objectives and procedures.”

The licensee was deficient in meeting this regulation because client #1 did not have a Centrally Stored Medication and Destruction Record on file.

7) Title 9, Section 10573(a)(7) Food Service Class B

The above section states, in part, ”All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption.”

The licensee was deficient in meeting this regulation because of the following:

• A food supply box was left outside the patio for several hours after delivery and was exposed to the sun.
• One of the kitchen refrigerators contained food that had mold and was spoiled.
• Approximately ten boxes of cookies, on top of the refrigerator, were expired for over a month.

**These deficiencies were corrected during the site visit.**

• Left over food in all the refrigerators did not have a label with a date.

8) Title 9, Section 10581(a) Building and Grounds Class C

The above sections states, in part, “Facilities shall be safe at all times for the safety and well-being of residents, employees and visitors.

The licensee was deficient in meeting this regulation because an excessive amount of knives (about 30) were stored in an unlocked kitchen cabinet.

9) Title 9, Section 10584(b) Fixtures, Furniture, Equipment and Supplies Class C

The above section states, in part, ”All window screens shall be in good repair.”

The licensee was deficient in meeting this regulation because the window screen in the dining area is broken.

Detailed Information
Census Data

TOTAL OCCUPANCY:
Approved: 17
Census: 14

TREATMENT CAPACITY:
Approved: 17
Census: 12