405800361-6-10-2021-29-AS-KBUY-C49TJV-20210623144654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800361
Report Date: 06/10/2021
Date Signed: 06/10/2021 02:24:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2021 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20210428122053

FACILITY NAME:	WYNDHAM RESIDENCE		FACILITY NUMBER:	405800361
ADMINISTRATOR:	JODI BELTRAMA		FACILITY TYPE:	741
ADDRESS:	222 S. ELM STREET		TELEPHONE:	(805) 474-7260
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	72	CENSUS: 55	DATE:	06/10/2021
		UNANNOUNCED	TIME BEGAN:	12:14 PM
MET WITH:	Jodi Beltrama/Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility is not following proper procedures to ensure sanitary conditions.

INVESTIGATION FINDINGS:

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At 12,20pm, Licensing Program Analyst (LPA) arrived at the facility to issue final findings to the complaint allegation listed above. LPA was rapid screened for COVID-19 upon entrance to the facility, and found negative by the rapid screening process. LPA met with Administrator Jodi Beltrama and informed her for the reason for the visit.

As to the allegation of, “Facility is not following proper procedures to ensure sanitary conditions.” Through interviews, documentation, video walk through, compliance history, photographic evidence, and Licensing Program Analyst (LPA) observation, adequate supply of Personal Protective Equipment (PPE) was stored at the facility and additional PPE was immediately available within hours from local parent company (Compass Health, Inc.). LPA was able establish that the facilities supply of PPE was sufficient for a facility with the capacity of 72 residents at the time of this complaint in the video walk through.

CONTINUED on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210428122053

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WYNDHAM RESIDENCE	FACILITY NUMBER: 405800361
	VISIT DATE: 06/10/2021

NARRATIVE

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Historical supply records of PPE on-hand at the facility via COVID-19 Welfare Calls documented on LIC812 on 11/12/2020 and 02/08/2021 indicated a thirty (30) day + supply of PPE was inventoried at the facility on those dates for historical reference. LAP confirmed through interviews and email that a PPE supply audit is performed weekly and that supplies are ordered at least every two weeks through Medline. LPA observed facility PPE supply request completed by parent company, Compass Health, Inc. within hours, as an alternate PPE supply resource. LPA observed through photographic evidence of 6 boxes, containing 9000 pairs of gloves of assorted sizes, less than 12 hours from initial complaint investigation. LPA interviewed 13 of 15 staff (S1-S13), S1-S11 indicated through interviews that at no time in the past 12 months did the facility lack PPE or cleaning supplies. Interviews of staff and manager provided no evidence of shortage of PPE supplies in the past 12 months. LPA discovered no evidence to support the allegation of, “Facility is not following proper procedures to ensure sanitary conditions.” Therefore, the allegation is unsubstantiated, at this time.

Exit interview, report emailed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021

LIC9099 (FAS) - (06/04)

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