405800361-7-27-2022-29-AS-RDLN-CGQVEH-20220727162222

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800361
Report Date: 07/27/2022
Date Signed: 07/27/2022 04:23:42 PM

Document Has Been Signed on 07/27/2022 04:23 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:	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: 56	DATE:	07/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Jodi Beltrama, Administrator		TIME COMPLETED:	04:35 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 an on site 1 year infection control annual visit to the facility above on 07/27/2022 at 3:30 PM . LPA met with Jodi Beltrama Administrator and explained the purpose of the visit. Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening. All staff, residents returning from an outing, and visitors wanting to come into the facility are required to sign in. All documentation is kept in a binder. The entry station has hand sanitizer along with a thermometer. The facility has a large activity room that is used for television, activities and exercise, all areas are spaced to accommodate as much space as possible for social distancing. All equipment and PPE supplies are kept in the RA office and stored under the stair case, all accessible to staff. Medications are kept in a locked medication room. The kitchen area has a dining area to accommodate distancing between residents when eating meals . The staff screen residents for symptoms and temperature 1x a day and documentation is kept in a binder. Increased monitoring is conducted if any change of condition is noted or any residents showing any signs, symptoms or have a temperature. Signs are posted on the hallway walls through out the facility regarding Covid-19 symptoms to report to staff, coughing and sneezing etiquette, hand hygiene, mask wearing and social distancing. All required postings are hung in common areas of the facility. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility has several areas for visiting inside, outside and in rooms. Continued 809C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

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: WYNDHAM RESIDENCE	FACILITY NUMBER: 405800361
	VISIT DATE: 07/27/2022

NARRATIVE

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The facility also offers virtual and telephone communications to all residents in care. Staff, residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Emergency Disaster plan has all agencies with telephone numbers listed. Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility staff will be assigned to only work with those quarantined/isolated individuals. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. Residents rooms all have own restroom for resident use. The facility has 3 public restrooms, hand hygiene signs are posted with supplies of soap and paper towels. Precautionary droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Trash bins have tight fitting lids. Facility has plans for delivering medications and meals to any quarantined/isolation room. The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Furniture has been moved around to accommodate social distancing between staff and residents as much as it can be. Elevators have signs for social distancing.

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: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: WYNDHAM RESIDENCE	FACILITY NUMBER: 405800361
	VISIT DATE: 07/27/2022

NARRATIVE

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Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap and paper towels. Staff files are locked in HR office and resident records are kept locked in RA office . Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed. The facility has a large outside courtyard with shade for residents use.

No deficiencies observed during the visit and all infection control protocols are implemented and followed.

Exit interview completed and copy of report emailed to Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

LIC809 (FAS) - (06/04)

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