405800193-12-2-2022-29-AS-RDLN-CLQTUD-20221202140209

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800193
Report Date: 12/02/2022
Date Signed: 12/02/2022 02:02:46 PM

Document Has Been Signed on 12/02/2022 02:02 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:	HILLSIDE VILLA RETIREMENT HOME #2		FACILITY NUMBER:	405800193
ADMINISTRATOR:	CONNIE K. RAY 98		FACILITY TYPE:	740
ADDRESS:	533 LE POINT STREET		TELEPHONE:	(805) 481-8384
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	6	CENSUS: 6	DATE:	12/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Connie Ray, Licensee/Administrator		TIME COMPLETED:	02:15 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 conducted a 1 year Infection Control Visit to the facility above. LPA met with Connie Ray, Licensee/Administrator and explained the purpose of the visit. LPA took a physical plant tour of the facility with Administrator and Staff. The facility has submitted a Mitigation Plan and Infection Control Plan to the department. The facility has an entry point through the garage where everyone entering completes sign-in and screening questions. All documentation is kept in binders. The entry station has hand sanitizer along with a thermometer. The facility has a living room to accommodate activities, a dining room for dining, all areas are spaced to accommodate as much space as possible for social distancing. All equipment and PPE supplies are kept in the garage cabinets. Medications are kept in a locked medication cabinet in staff office. The staff screen residents for symptoms every morning. Increased monitoring is conducted if any change of condition are noted on any residents showing symptoms or has a temperature. Signs are posted on the entry area and walls in common areas regarding Covid-19. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility has areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before residing or working in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

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: HILLSIDE VILLA RETIREMENT HOME #2	FACILITY NUMBER: 405800193
	VISIT DATE: 12/02/2022

NARRATIVE

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Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverage if needed. If any suspected or confirmed cases of Covid-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals. Staff will use full PPE with N95 masks with face shields when dealing with any pending or confirmed cases of Covid-19. The facility has 3 resident bedrooms and 2 bathrooms. Restrooms are being disinfected. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room. The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in locked cabinet in the garage. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. Fire extinguishers are charged and last inspected 08/03/2022. Administrator Certificate is valid expires 2024. Smoke and carbon monoxide detectors are present. Food Service requirements of 2 day perishable and 7 day Non-perishable are met. No deficiencies observed during the visit and all infection control protocols are implemented and followed.

Exit interview completed and copy of report emailed to Administrator/Licensee.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

LIC809 (FAS) - (06/04)

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