405800193-12-21-2023-29-AS-RDLN-CYR433-20231221174403

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800193
Report Date: 12/21/2023
Date Signed: 12/21/2023 05:44:23 PM

Document Has Been Signed on 12/21/2023 05:44 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. #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: 5	DATE:	12/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Connie Ray, Administrator		TIME COMPLETED:	01:30 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 10:00am to conduct a 1 year annual visit to the facility above. LPA met Administrator Connie Ray 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 a current infection Control Plan on file. The facility has a sign in and out note pad with hand sanitizer at garage door entry. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. 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 3 bedroom and 2 bathroom currently occupying 5 residents and employs 5 staff, 1 Administrator and 2 back up staff if needed. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. Carbon Monoxide detector was tested and alarmed properly. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. 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 and locked in garage or under locked kitchen sink. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard and front yard for client use. The facility has two gates one on each side of the house and due to normal wear and tear they are no longer self closing and self latching, Administrator will have staff fix gates. The facility has telephone and internet service for resident use. 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: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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: HILLSIDE VILLA RETIREMENT HOME #2	FACILITY NUMBER: 405800193
	VISIT DATE: 12/21/2023

NARRATIVE

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Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 09/01/2024. The facility is approved for a capacity of 6 Non- Ambulatory and Hospice waiver approved for 3 residents.

Staffing: The facility employes 5 staff, 1 Administrators and 2 additional back up staff when needed. Staff records are kept confidential. LPA reviewed 5 staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions on file. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. Administrator's Certificates expired on 10/26/2024.

Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for 2023 Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements, PPE and Quarterly Disaster Drills. Staff handling medications had required 8 hours of medication training. Trainers meets requirements to train staff. Initial staff training was kept on file.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The Facility does not handle cash resources for any of the residents in care. Facility does submit resident incident reports to the department when required.
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 40 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 from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. 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: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/21/2023 05:44 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(h)

Care of Persons with Dementia

(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in two gates one on each side of house are no longer self closing or self lathching which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/28/2023
	Plan of Correction
1 2 3 4	Administrator agreed to have both gates fixed to be self-closing and slef-lathcing and send video or photgraphic proof to CCL.

Type B

Section Cited

HSC

1569.695(e)(2)

(e) A facility shall have all of the following readily avaiable to the facility staff during an emergency: (2) An Apprsal of Residents needs and services plan for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 0 out 5 residents did not have an ANS in their emergency packets which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/28/2023
	Plan of Correction
1 2 3 4	Administrator agreed to make copies of ANS for each resident and put them in each residents emergency packets.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: 12/21/2023

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Incidental Medical & Dental: The facility has a locked medication cabinet in the medication room/office. Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The medications records were reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected residents medications for all prescription and PRN medications with Doctors orders, no medications labels were altered, medications are stored in original containers and no medications were expired. The facility has a locked box for refrigerated medications if required. In an evacuation medications will be placed in ice chest with ice packs to keep cold if utilities are affected. The facility has a red sharps container for disposal of syringes. Administrator and 1 other staff take medications to the pharmacy for destruct.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 08/01/2023. Emergency exits and telephone numbers were posted. Emergency information packets were missing residents ANS forms, Administrator will make copies from residents files and add them to the packets. A set of keys is available for staff on all shifts to access full facility capacity in an emergency.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have delayed egress. The facility does not currently have any residents using oxygen. The facility does not currently have any hospice resident in care. The facility does not currently have any resident on Home Health services. The facility has working exiting door alarms for the safety of residents in care.

LPA conducted interviews with 3 staff and 3 residents.

Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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