405800269-10-6-2023-29-AS-RDLN-CWCVL2-20231006163113

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800269
Report Date: 10/06/2023
Date Signed: 10/06/2023 04:32:48 PM

Document Has Been Signed on 10/06/2023 04:32 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:	M & L SOUTH BAY MAXI CARE		FACILITY NUMBER:	405800269
ADMINISTRATOR:	LITA C. LAZO		FACILITY TYPE:	740
ADDRESS:	1820 MOUNTAIN VIEW DRIVE		TELEPHONE:	(805) 528-7862
CITY:	LOS OSOS	STATE: CA	ZIP CODE:	93402
CAPACITY:	6	CENSUS: 5	DATE:	10/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Lita Lazo, Licensee/Administrator		TIME COMPLETED:	04:40 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 annual visit to the facility above. LPA met with Licensee/Administrator Lita Lazo and explained the purpose of the visit. LPA requested the following records from the Administrator: LIC, 500 Staff Roster, Register of Residents, Emergency & Disaster Plan, Documentation of Quarterly Emergency Drills, Copy of Liability Insurance, Copy of Admission Agreement with Addendums, Copy of Annual Fire Inspection/Certification of Fire System. A tour of the inside and outside of the facility was conducted with Administrator. 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. 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 need to tight fitting lids. Physical Plant & Environmental Safety: The facility is a 8 bedroom and 10 bathroom currently occupying 5 residents and employs 4 staff. The facility currently has 2 live-in staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for residents 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. 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: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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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Document Has Been Signed on 10/06/2023 04:32 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: M & L SOUTH BAY MAXI CARE	FACILITY NUMBER: 405800269
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2023

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 observation, the licensee did not comply with the section cited above in the gate is no longer self closing and self lathcing due to normal wear and tear and needs repair which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Administrator will make sure all property is fenced with self closing and self lathcing gates and fix anything needing repair and send video/photograph showing repairs completed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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: M & L SOUTH BAY MAXI CARE	FACILITY NUMBER: 405800269
	VISIT DATE: 10/06/2023

NARRATIVE

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Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and locked in garage and locked in cupboards. The facility has sufficient space inside and outside for activities and visiting. The facility has a pathway around the house and a sitting area in front yard for client use with shade. The facility has telephone and internet service for resident use. The facility provides resident with a shared computer with confidential internet access.

Operational Requirements: The facility has a current plan of operation and infection control plan 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 08/01/2024. The facility is approved for a capacity of 6 Non- Ambulatory, and Hospice approved for 3 residents.

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.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 10/22/2022. 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. The facility has a generator for emergencies and for back up power outages.

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 currently have any residents on oxygen. The facility does not currently have any hospice residents in care. Hospice care plans are kept on file and up to date for any residents on hospice services.. The facility currently has 1 resident on Home Health services. Home Health services records are kept on file. The facility has exiting door alarms for the safety of residents in care.
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: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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: M & L SOUTH BAY MAXI CARE	FACILITY NUMBER: 405800269
	VISIT DATE: 10/06/2023

NARRATIVE

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Staffing: The facility employes 4 staff and 1 Administrators Staff records are kept confidential. LPA will return at a later date to review staff records.

Personnel Records & Training: The facility keeps confidential files for each staff member. LPA will return at a later date to review staff training records.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. LPA will return at a later date to review resident records.

Incidental Medical & Dental: The facility has a locked medication cupboard in the dining room area. Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. LPA will return at a later date to review medications and medication records.

LPA will conduct interview with staff and residents upon return to complete the annual visit.

Exit interview conducted, deficiency 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: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

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