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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800333
Report Date: 03/22/2024
Date Signed: 03/22/2024 04:49:19 PM

Document Has Been Signed on 03/22/2024 04:49 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:RANDYN TORRESFACILITY TYPE:
735
ADDRESS:8902 PALOMARTELEPHONE:
(805) 462-2421
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 6CENSUS: 5DATE:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Joni Chapman, Back up AdministratorTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) De Leon arrived at 9:30am to conducted a 1 year annual visit to the facility above. LPA met with Back up Administrator Joni Chapman 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 submitted a current Infection Control Plan to the department. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, and hand soap. 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, 2 common area bathrooms currently occupying 5 residents and employs 8 staff with 1 being Administrator. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke alarms. At 2:00pm LPA and staff were unable to locate a carbon monoxide, Administrator is purchasing today. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen is clean, safe and sanitary. Toilet, hand washing and bathing facilities are operational. 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 locked in cabinet in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard and front yard at 10:00am LPA did not see any shaded areas for resident use and the side gate no longer is self closing and self latching. The facility has telephone and internet service for resident use. Water temperatures were tested and at 10:30AM bathroom #1 measured at 123.8 F.
Continued 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: C.A.L.L.-PALOMAR HOUSE
FACILITY NUMBER: 405800333
VISIT DATE: 03/22/2024
NARRATIVE
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Operational Requirements: The facility has a current plan of operation with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity 6 with 5 being Ambulatory and 1 being Non-Ambulatory. The facility has exiting door alarms.

Staffing: The facility employes 7 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 CPI certificates. 5/5 staff did not have CPI Certificates, 2/5 staff were missing Job applications, Health screening and TB results.

Personnel Records & Training: The facility keeps confidential files for each staff member. 5/5 staff had current 1st AID/CPR. 5/5 Staff training records were not on file at the facility. Facility provided a sheet of staff and the training dates but no records of training's or material presented. At 2:00pm LPA could not determine if staff had annual training of the required 8 hours.

Clients Rights: All require postings were posted in the common area of the facility. Personal rights and Persons with disabilities, Non-discrimination notice, CCL Complaint poster 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 resident confidentially. 5/5 files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS) are done as IPP and ISP and completed quarterly and annually, 2/5 did not have TB results, Personal Rights, and Safeguard for personal property and valuables. The Facility does handle cash resources for all 5 residents in care. LPA audited all 5 residents funds with ledgers, cash, and receipts ,all balancing. The facility Surety bond is current. Facility does submit 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 45 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. A menu is posted for residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
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: C.A.L.L.-PALOMAR HOUSE
FACILITY NUMBER: 405800333
VISIT DATE: 03/22/2024
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Health Related Services: Facility provides Centrally Stored Medications to all clients in care. First Aid is provided to clients in care. Clients medication records were reviewed, prescriptions had doctors orders, and PRN and medications were checked for expiration date, stored in original container and no medications labels were altered.

Incidental Medical Services: Facility provides or assist in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) and the Centrally Stored Medication and Destruct Record (CSMDR). Administrator and staff do medication destruction.

Disaster Preparedness: The current emergency disaster forms are not posted, the old form was posted. LPA told administrator to update with the new revision to the 9 page form. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 12/14/2023. 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.

Emergency Intervention: The facility does not keep staff's CPI Non-Violent Crisis Intervention Training Certificates, Administrator will provide to LPA.


LPA conducted interviews with 2 Staff. 5 Residents were out of the facility at time of visit and unable to be interviewed.

Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/22/2024 04:49 PM - It Cannot Be Edited


Created By: Rachael De Leon On 03/22/2024 at 02:46 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: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the facility did not have a carbon monoxide detector which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2024
Plan of Correction
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Administrator will purchase and install a new carbon monixde detector later today and send a picture to CCL.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in bathroom #1 measured at 123.8 F which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Administrator will make a log and test water 3 x's a day and adjust water heater so bathrooms measure below 120 degress F at all times. Prpvide log to CCL.
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:Rachael De Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/22/2024 04:49 PM - It Cannot Be Edited


Created By: Rachael De Leon On 03/22/2024 at 02:46 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: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the facility does not have shade for residents when outside which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Administrator agreed to provide an umbrella or other shaded device for resident use. Administrator will send CCL a picture to clear the POC.
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review the licensee did not comply with the regualtion above in 2/5 staff did not have a health screening with a TB result on file at the facility which poses a potential health and safety risk to residents in care.
POC Due Date: 03/29/2024
Plan of Correction
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Administrator agreed to provide 2/5 staffs health screening with TB results to CCL by sending a copy of the forms.
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:Rachael De Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/22/2024 04:49 PM - It Cannot Be Edited


Created By: Rachael De Leon On 03/22/2024 at 02:46 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: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2/5 staff did not have a file at the facility with health screening with TB results on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Administrator agreed to send CCL 2/5 staff copy of health screening with TB results.
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2/5 residents did not have a TB result on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Administrator agreed to send CCL 2/5 residents copies of TB results to CCL.
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:Rachael De Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
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