405800506-3-21-2024-29-AS-RDLN-D3KVXH-20240321164935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800506
Report Date: 03/21/2024
Date Signed: 03/21/2024 04:49:44 PM

Document Has Been Signed on 03/21/2024 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:	GAYNFAIR HOUSE		FACILITY NUMBER:	405800506
ADMINISTRATOR:	NEREIDA LEAL		FACILITY TYPE:	735
ADDRESS:	545 GAYNFAIR TERRACE		TELEPHONE:	(805) 473-3542
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY: 6		CENSUS: 6	DATE:	03/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Nereida Leal, Administrator		TIME COMPLETED:	05:00 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 2:50pm to conducted a 1 year annual visit to the facility above. LPA met with Administrator Nereida Leal 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 4 bedroom with 1 shared resident bathroom, and 2 common area bathrooms currently occupying 6 residents and employs 6 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 and a carbon monoxide detector. 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 under kitchen sink and in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard and front yard at 4:00pm LPA did not find any out door furniture or umbrella for resident use. The facility has telephone and internet service for resident use. Water temperatures were tested and within regulation requirements, bathroom #1 measured at 109.8 F. 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 6 being Non-Ambulatory. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

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: GAYNFAIR HOUSE	FACILITY NUMBER: 405800506
	VISIT DATE: 03/21/2024

NARRATIVE

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Staffing: LPA will return at a later date to review staff files.
Personnel Records & Training: LPA will return at a later date to review staff training records.

Clients Rights: All require postings were posted in the common area of the facility. Personal rights, CCL Complaint poster is posted. The current license along with CCL reports and PIN's were posted. Internet is provided to each client and each client is given confidentiality and privacy.

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. 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.

Clients Records & Incident Reports: LPA will return at a later date to review resident files.
Health Related Services: LPA will return at a later date to review medical and dental records.
Incidental Medical Services: Facility 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). LPA will return at a later date to review medications.

Disaster Preparedness: The forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 08/15/2023. 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 use restraints or seclusion. The facility does take the CPI Non-Violent Crisis Intervention Training. Staff Certificates provided to LPA.

LPA will conduct interviews with staff and residents at a later date.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 03/21/2024 04:49 PM - It Cannot Be Edited

Created By: Rachael De Leon On 03/21/2024 at 04:32 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: GAYNFAIR HOUSE	FACILITY NUMBER: 405800506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2024

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in Facility residents do not have a furnished shaded area for use which poses a potential personal rights risk to persons in care.
	POC Due Date: 03/28/2024
	Plan of Correction
1 2 3 4	Administrator agreed to get furniture and umbrella for residents outside use.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC809 (FAS) - (06/04)

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