405800279-11-21-2024-29-AS-RDLN-DB8RQA-20241121121312

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800279
Report Date: 11/21/2024
Date Signed: 11/21/2024 12:13:19 PM

Document Has Been Signed on 11/21/2024 12:13 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:	SPRUCE DAY PROGRAM		FACILITY NUMBER:	405800279
ADMINISTRATOR/ DIRECTOR:	TODD HOVE		FACILITY TYPE:	775
ADDRESS:	250 SPRUCE STREET		TELEPHONE:	(805) 473-3005
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY: 45		CENSUS: 17	DATE:	11/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:50 AM
MET WITH:	Todd Hove, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:20 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 9:50am to conducted a 1 year annual visit to the facility above. LPA met with Administrator Todd Hove 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 Adult Day Program (ADP) has submitted a current Infection Control Plan to the department. The facility has a sign in and out binder for visitors at 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 placed in isolation room until picked up from program. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and waste baskets have covers. Physical Plant & Environmental Safety: The facility has 1 large room, 2 restrooms, Kitchen and 2 offices currently occupying 17 clients and employs 12 staff, and 1 Administrator. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and 1 carbon monoxide detectors. The lighting is sufficient for the use of the facility and for clients comfort. The facility kitchen is clean, safe and sanitary. Toilet and hand washing facilities are operational. The pathways are clear of any obstructions. Disinfectant, cleaning solutions and poisons are inaccessible to clients in care locked in supply closet and locked under kitchen sink. The facility has sufficient space inside for activities and visiting. The facility has telephone and internet service for clients. Water temperatures were checked in bathroom #2 at 114.8 degrees F. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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: SPRUCE DAY PROGRAM	FACILITY NUMBER: 405800279
	VISIT DATE: 11/21/2024

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 is approved for a capacity of 45 with 45 being Non-Ambulatory clients.

Staffing: The facility employes 12 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 staff files for 1st AID/CPR, Finger print clearances, Applications, Health exam with TB results, Criminal Record statement and Administrator file was reviewed for education and training hour requirements.

Personnel Records & Training: The facility keeps confidential files for each staff member. 5/5 staff had current 1st AID/CPR, records were present, up to date and kept confidential. Initial and Annual Training requirements are being met. All staff files had 8 plus hours of Annual training.

Clients Rights: All require postings were posted in the common area of the program. Personal rights and Persons with disabilities are posted in the common areas of the program. The current license is posted. Internet is provided to each client and each client is given confidentiality and privacy.

Clients Records & Incident Reports: The facility keeps separate files on each clients 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, and Personal Rights. The Facility does not handle cash resources. Facility does submit incident reports to the department when required.

Food Service: THE ADP only has a microwave and refrigerator on the premises. Food, snacks and drinks are brought to program by clients. The facility handles and prepares food safely. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees. All food is covered, stored and marked appropriately. ADP keeps extra snacks available if needed. 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. Drinking water is available to all clients.

Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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: SPRUCE DAY PROGRAM	FACILITY NUMBER: 405800279
	VISIT DATE: 11/21/2024

NARRATIVE

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Health Related Services: Facility provides Centrally Stored Medications to clients in care. First Aid is provided to clients in care. Clients medication records were reviewed, prescriptions and PRN medications were checked for expiration date, stored in original container, no lables were altered. Currently 1 client at program takes daily medications, about 6 clients have PRN if needed. All medications are locked in cabinet in the kitchen.

Incidental Medical Services: The ADP contacts clients responsible parties for medical and dental services. The ADP uses the Medication Administration Record (MAR) and the Centrally Stored Medication and Destruct Record (CSMDR). The program has annual check up for client in care.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts disaster drills every 6 months. The fire extinguishers were charged and last inspected 07/22/2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full program in an emergency.

Emergency Intervention: The facility does not use manual restraint or seclusion on any clients in care.

LPA conducted interviews with 3 Clients and staff.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC809 (FAS) - (06/04)

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