197606257-7-21-2023-29-AS-BBAI-CTXPXA-20230721114202

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606257
Report Date: 07/21/2023
Date Signed: 07/21/2023 11:42:15 AM

Document Has Been Signed on 07/21/2023 11:42 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:	EASTER SEALS SOUTHERN CALIFORNIA PASO ROBLES HOUSE		FACILITY NUMBER:	197606257
ADMINISTRATOR:	LISA MARIE MCDONALD		FACILITY TYPE:	735
ADDRESS:	7306 PASO ROBLES AVE		TELEPHONE:	(818) 609-8227
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY: 3		CENSUS: 1	DATE:	07/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Juana Gomez -		TIME COMPLETED:	11:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility. LPA met with DSP's Paul Wright and Juana Gomez and explained the reason for the visit. Administrator Danny Tapia was unable to make the visit , but informed LPA that either Paul or Juana can sign report in their absence. A tour of the physical plant was conducted with Paul approximately between 9:30am - 10:30am LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The following was noted: Facility is a single story residence consists of three (3) resident bedrooms and three (3) bathrooms. LPA observed fully charged fire extinguishers last serviced in January of 2023. All smoke alarms and carbon monoxide detector were tested and functioned properly during time of visit. Emergency drill was last conducted June 2023. LPA observed required postings throughout the facility. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; Sharp objects are stored in a locked cabinet to the left of the washer and dryer. Medications, first aid and cleaning supplies were observed stored in this locked cabinet as well. Cabinets above the washer and dryer were observed to store non-perishable food and snacks. Bedrooms: The resident bedrooms were 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. At approximately 10:00am, LPA observed resident listening to music in the backyard under the shaded patio area.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
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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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: EASTER SEALS SOUTHERN CALIFORNIA PASO ROBLES HOUSE	FACILITY NUMBER: 197606257
	VISIT DATE: 07/21/2023

NARRATIVE

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Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. The hot water was measured in each bathroom during physical plant tour. Hot water measured within the required limit of 105-120 degrees Fahrenheit in all bathrooms during visit.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. LPA observed board games and other activities stored beneath a side table next to the couch.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. Entry/exits were free of obstruction during the time of the visit. There is a detached garage located on the premises. LPA observed garage to store extra PPE supplies, medical supplies, extra furniture and cleaning supplies.

The LPA spoke with Juana Gomez regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate each bedroom as a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if anyone shows any symptoms or exposures. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Medications: Medications review began at 10:30am The medications are centrally stored in a locked cabinet above the microwave. LPA reviewed medications for the one (1) resident in care. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA PASO ROBLES HOUSE	FACILITY NUMBER: 197606257
	VISIT DATE: 07/21/2023

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Records: LPA began reviewing Personnel and Resident Records at 10:50am. One (1) resident files was reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records appeared to be order. Two (2) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records appeared to be in order.

LPA interviewed Staff at approximately 10:15am. LPA attempted to interview resident at 9:45am, but resident declined to interview.

During today’s visit, the LPAs obtained copies of the following: staff roster, staff schedule, and resident roster.

Exit interview conducted, report issued and sent via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
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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