197606814-9-29-2021-31-AS-MSPH-C7BVST-20210929164205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606814
Report Date: 09/29/2021
Date Signed: 09/29/2021 04:44:13 PM

Document Has Been Signed on 09/29/2021 04:44 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PROJECT INDEPENDENCE		FACILITY NUMBER:	197606814
ADMINISTRATOR:	KATHLEEN MILLER		FACILITY TYPE:	775
ADDRESS:	43439 COPELAND CIRCLE		TELEPHONE:	(661) 948-8402
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY: 102		CENSUS: 45	DATE:	09/29/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Lorraine McKesson		TIME COMPLETED:	04:45 PM

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	LPA Spaeth and LPA Stamps conducted an unannounced case management -incident report visit and arrived at 2:00 pm. Upon entering the facility, LPAs' temperatures were recorded. Both LPAs were instructed to sign in and confirm if have any COVID symptoms. Both parties were greeted by Lorraine McKesson, Manager - DTAC Services at 2:05 pm. LPA Spaeth stated the purpose of the visit was regarding an incident report received by CCL which alleged the personal rights of a consumer were violated. LPA Spaeth and LPA Stamps met with Manager in the conference room. Both parties interviewed Manager from approximately 2:05 pm until 2:35 pm. LPA Spaeth requested documentation from Manager at approximately 2:15 pm and LPA received copies of the documentation. LPA Spaeth and LPA Stamps were then escorted by the Manager on a tour of the location. At approximately 2:25 pm, Manager entered the isolation room which is in the administrative office location. LPAs observed a couch and PPE items such as face shields, surgical masks, gloves, gowns, and hand sanitizer. LPA Spaeth observed a 90 day supply available for all staff. Manager stated would use the room for any consumer who might exhibit COVID symptoms. All parties exited a door which led to the north side of the building. LPAs observed a consumer with a staff member were exiting out the north side door for pick up by a family member. The Manager stated all staff and consumers exit out of the north door. LPAs observed the kitchen and Manager stated the kitchen is closed due to COVID. However, Manager confirmed all consumers bring a cold lunch. The Manager explained that when consumers arrive, consumers participate in the program from 8:15 am until 3:15 pm in a specific program room location. All consumers will eat lunch in the designated program room so the consumers stay in the same room for the entire day. LPAs observed six program rooms which contained

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PROJECT INDEPENDENCE	FACILITY NUMBER: 197606814
	VISIT DATE: 09/29/2021

NARRATIVE

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between three to ten consumers in each room. All consumers were social distanced at work tables. LPAs observed consumers working on various projects.

LPA Spaeth observed wall hand sanitizer stations throughout the facility. LPA Spaeth observed tissues and hand sanitizer available in each classroom for consumers' use. All parties then walked to the front entrance and was informed by the Manager that all staff and consumers enter each morning at the front entrance. The Manager stated a cart is rolled outside and when consumers arrive via transportation vans, the consumers' temperatures are recorded and written down by the Manager. If a consumer has a temperature, the consumer's family is called for pick up. Manager stated the van drivers will take the consumer's temperature and will ask the COVID questions when picking up the consumers at the group home or family home location. The Manager stated some of the consumers are not able to answer the questions so the responsible party is asked when the driver picks up the consumers. If a consumer has a temperature or is exhibiting any COVID symptoms, the consumer is then asked to stay home for that day.

LPA Stamps asked the number of times the location is cleaned. The manager stated at least two times a day. The manager also stated the frequently touched surfaces are sanitized two times per day. Also the staff who work with the consumers will sanitize the tables several times per day. The Manager left the location at 3:20 pm and explained the Jordan Williams will be able to sign the report.

LPA Stamps observed the bathrooms at 3:40 pm. There are male and female bathroos for consumers. There is a separate bathroom for all staff members which contained hand soap, paper towels, and trash can. The female consumer bathroom contained wash your hands sign, hand soap, paper towels and a trash can. LPA Stamps viewed the male bathroom and observed hand soap, paper towels, and a trash can. However there was not a wash your hand sign in the male bathroom and in the staff bathroom. LPA Spaeth observed the appropriate signs were posted in the bathrooms and the front door at approximately 4:30 pm. There are no deficiencies to report at this time. In regard to the incident report, further investigation is needed. Exit interview was conducted, appeal rights discussed, and a copy of the report was emailed to the Manager.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC809 (FAS) - (06/04)

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