405800130-4-11-2024-29-AS-RDLN-D48V8L-20240411161254

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800130
Report Date: 04/11/2024
Date Signed: 04/11/2024 04:14:26 PM

Document Has Been Signed on 04/11/2024 04:14 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	C.A.L.L.-RAMONA HOUSE		FACILITY NUMBER:	405800130
ADMINISTRATOR/ DIRECTOR:	RANDYN TORRES		FACILITY TYPE:	735
ADDRESS:	3355 RAMONA ROAD		TELEPHONE:	(805) 466-2909
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY: 4		CENSUS: 4	DATE:	04/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:45 AM
MET WITH:	Back up Administrator Joni Chapman		TIME VISIT/ INSPECTION COMPLETED:	04:20 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	Licensing Program Analyst (LPA) De Leon arrived at 10:45am to conducted a 1 year annual visit to the facility above. LPA met with Back up Administrator Joni Chapman and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Infection Control Plan to the department. The facility has hand sanitizer at entry. The bathrooms have toilet paper, paper towels, and hand soap. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and waste baskets have tight fitting covers. Physical Plant & Environmental Safety: The facility is a 4 bedroom with 1 bathroom and 1 common area bathroom currently occupying 4 residents and employs 6 staff with 1 being Administrator. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke alarms and a dual carbon monoxide detector. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen is clean, safe and sanitary. Toilet, hand washing and bathing facilities are operational. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked under kitchen sink and in laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard with furniture and shade for resident use. The facility has telephone and internet service for resident use. Water temperatures were tested and within regulation requirements, bathroom #1 measured at 107.8F. Operational Requirements: The facility has a current plan of operation with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity 4 with 4 being Ambulatory. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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 13

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: C.A.L.L.-RAMONA HOUSE	FACILITY NUMBER: 405800130
	VISIT DATE: 04/11/2024

NARRATIVE

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Staffing: LPA reviewed 5 staff files for Applications, Finger print clearances or exemptions, Health Screening with TB results. All files were up to date with all required forms. Administrator file was reviewed for Administrator Certificate and education requirements, Staff Administrator files are kept at the local C.A.L.L Program office, LPA asked for files to be at the facility for administrator with Valid administrator certificate, education and training.

Personnel Records & Training: LPA reviewed 5 staff files for valid 1st Aid & CPR. The program is in the process of making up Training binders at each facility covering staff that work at that facility. LPA went over the requirements of training for the facility and the information that needs to be on the training records.

Clients Records & Incident Reports: LPA reviewed 4 Resident files for Signed Admission Agreements, ID and emergency information form, Medical Assessments with TB results, Consent forms, Appraisal Needs and Services Plan (ANS), Personal Rights, Safeguard for Property & Valuables, and Safeguard for Cash Resources. Incident Reports are sent to CCL on residents when required. All files reviewed were up to date with all required forms. LPA audited P&I funds for each clients with ledgers, receipts, cash and all clients balanced.

Clients Rights: All require postings were posted in the common area of the facility. Personal rights, CCL Complaint form is posted. The current license is posted. CCL reports and PIN's were in a binder for review. Internet is provided to each client and each client is given confidentiality and privacy.

Health Related Services: Facility provides first aid to residents when needed. Facility provides or assists in providing transportation to medical and dental appointments, when needed. Facility centrally stores medication for all residents in care. The facility uses the Medication Administration Record (MAR) and the Centrally Stored Medication and Destruct Record (CSMDR).

Incidental Medical Services: Medication were audited on all 4 residents in care, LPA found no expired medications, no labels altered, and all medications are stored in original containers.

Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

Page: 13 of 13

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: C.A.L.L.-RAMONA HOUSE	FACILITY NUMBER: 405800130
	VISIT DATE: 04/11/2024

NARRATIVE

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Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 45 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices.

Disaster Preparedness: The forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 12/14/2023. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Emergency Intervention: The Facility does not use restraints or seclusion. The facility does take the CPI Non-Violent Crisis Intervention Training, 2 staff are expired and taking the course in May 2024.

LPA conducted interview with 1 staff and 1 staff and all 4 residents were out in the community and unable to interview at this time.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

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