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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800333
Report Date: 01/25/2023
Date Signed: 01/25/2023 01:53:59 PM

Document Has Been Signed on 01/25/2023 01:53 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.-PALOMAR HOUSEFACILITY NUMBER:
405800333
ADMINISTRATOR:REGINA R. CEASARFACILITY TYPE:
735
ADDRESS:8902 PALOMARTELEPHONE:
(805) 462-2421
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 6CENSUS: 6DATE:
01/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Randyn Torres, AdministratorTIME COMPLETED:
02:05 PM
NARRATIVE
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On 1/25/23 at 11:30 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced annual infection control inspection of the facility above. LPA met with Randyn Torres, Administrator, and explained the reason for the visit.

LPA toured the facility with the administrator and observed the following: Upon entry to the facility, LPA was screened, however, administrator was not wearing a mask. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions. The facility did not protect the personal rights of clients in care to be able to receive safe and healthful accommodations in that the facility staff failed to wear face coverings while providing care and supervision to clients in care. Pursuant to Title 22, California Code of Regulations, the deficiency will be cited on 809-D. During the tour, LPA also observed: The facility has infection control signage. There are soap and paper towel dispensers in client bathrooms (2). Fire extinguishers (2) are located in the kitchen and garage. The extinguishers are fully charged and were inspected on 11/22/22. At 11:50 am, LPA observed the freezer temperature in the garage which displayed 10F degrees. Administrator adjusted temperature and by 1:05 pm, the temperature read 0F degrees. At 11:56 am, LPA observed a cabinet with client records unlocked in the administrator’s unlocked office. The licensee has the responsibility to safeguard the confidentiality of client records. Deficiency cited. LPA observed the bathroom shower missing a door handle. Licensee will install a handle, take a photo and send to LPA by 2/1/23. The facility’s oven has a broken tray at the bottom, front of the oven. Licensee will repair the tray, take a photo, and send to LPA by 2/1/23. At 1:12 pm, LPA interviewed the administrator. Administrator states she has been the administrator since September 2022. CCL records indicate Staff #1 (S1) as the administrator. Administrator reached out to Executive Director Chris Quattlebaum who confirms the documentation has not been sent to CCL. The facility failed to report the change of administrator to CCL within the 30-day requirement. Deficiency cited.

At 12:17 pm, LPA conducted the Infection Control mitigation module with the administrator.


Exit interview conducted, deficiencies cited, and the report and appeal rights emailed to the executive director and administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
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 01/25/2023 01:53 PM - It Cannot Be Edited


Created By: Darlene Chavez On 01/25/2023 at 01:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: C.A.L.L.-PALOMAR HOUSE
FACILITY NUMBER: 405800333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(2)
80072(a)(2) Personal Rights
(a) Except for children’s client facilities, each client shall have personal rights which include, but are not limited to, the following:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the facility failed to ensure staff were wearing face coverings which poses an immediate health, safety and personal rights risk to clients in care.
POC Due Date: 01/26/2023
Plan of Correction
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Administrator has committed to creating a display which prompts staff to put on masks as soon as they sign-in for the day. Administrator will conduct infectious control training with staff, emphasizing the reasons for proper use of PPE for clients and staff. A staff sign-in sheet from the training with staff printed names, signatures, and date of training will be sent to LPA by 1/31/23. Administrator will send CCL a written commitment by 1/26/23 stating that this training will be conducted.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023


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Document Has Been Signed on 01/25/2023 01:53 PM - It Cannot Be Edited


Created By: Darlene Chavez On 01/25/2023 at 01:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: C.A.L.L.-PALOMAR HOUSE
FACILITY NUMBER: 405800333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(c)(1)
80070(c)(1) Client Records
(c) All information and records obtained from or regarding clients shall be confidential.
(1) The licensee shall be responsible for safeguarding the confidentiality of record contents. This requirement has not been met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility failed to secure client records. The administrator’s office and cabinet were unlocked containing client records which poses a potential health and safety risk to clients in care.
POC Due Date: 02/01/2023
Plan of Correction
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Administrator has committed to securing the office at all times. Administrator will create signage to prompt a reminder to lock the office, take a photo of this signage and send to CCL by 2/1/23.
Type B
Section Cited
CCR
85061(b)
85061(b) Reporting Requirements
(b) The licensee shall notify the licensing agency, in writing, within 30 days of a change of administrator. Such notification shall include the following: (1) Name, and residence and mailing addresses of the new administrator…..This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on interviews and records review, the licensee failed to report a change of administrator within the time required.
POC Due Date: 02/01/2023
Plan of Correction
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Licensee will submit documentation for change of administrator to CCL by 2/1/23.
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
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023


LIC809 (FAS) - (06/04)
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