405800568-5-3-2023-29-AS-DCHZ-CRGU8C-20230503152118

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800568
Report Date: 05/03/2023
Date Signed: 05/03/2023 03:22:48 PM

Document Has Been Signed on 05/03/2023 03:22 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.-D.T.A.C.		FACILITY NUMBER:	405800568
ADMINISTRATOR:	REGINA CEASAR		FACILITY TYPE:	775
ADDRESS:	11700 VIEJO CAMINO		TELEPHONE:	(805) 466-0766
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY: 45		CENSUS: 26	DATE:	05/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Regina Ceasar, Administrator		TIME COMPLETED:	03:45 PM

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Licensing Program Analyst (LPA) Chavez conducted an unannounced Annual/Required visit. LPA met with Regina Ceasar, Administrator. Also in attendance was Jeff Edler, Tri-Counties Regional Center, Quality Assurance Specialist (QAS).

LPA and QAS toured facility with the administrator, inside and out. The program is mostly community based with some individuals receiving services at-home only. Hot water temperature measured between 113.5 F and 117.9 F degrees. All toilets and hand washing facilities are maintained in a safe, sanitary, operating condition. The program site is clean, safe, sanitary and in good repair for the safety and well-being of clients, employees, and visitors. Facility is maintained in conformity with state fire marshal regulations. Smoke detectors/carbon monoxide detectors were tested and functioning. Each client is accorded safe, healthful, and comfortable accommodations, furnishings and equipment to meet his/her needs. Snacks are provided and clients bring their own lunches. Food is stored and prepared in a safe and healthful manner. Disinfectants, cleaning solutions and poisons are inaccessible to individuals. Facility has adequate emergency and first aid supplies. Fire extinguishers (2) were located in the large activity room and near the kitchen. Extinguishers were fully charged and last inspected on 11/22/22. Facility temperature is about 70 degrees. Outdoor walkways are free from obstruction and the facility has fenced outside areas for individuals to use. Centrally stored medications are safe, locked and inaccessible to clients. The Centrally Stored Medication and Destruction Records had not been recorded since 2020. The administrator states that they stopped recording the medications when clients were not coming to the facility due to COVID-19. Administrator says they did not start the process back-up when clients returned. Technical violation given. LPA observed staff sufficient for client ratio. The last emergency disaster drill was conducted on 3/10/23. LPA conducted a file review of 5 clients. Client files reviewed had admission agreements and current needs and services plans, however, 2 out of 5 client files reviewed did not contain physician reports with TB results. Deficiency cited.

Continued on 809-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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 05/03/2023 03:22 PM - It Cannot Be Edited

Created By: Darlene Chavez On 05/03/2023 at 02:57 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.-D.T.A.C.	FACILITY NUMBER: 405800568
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82069(b)(1)

Client Medical Assessments

(b) 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
1 2 3 4	Based on record review, two out of five clients did not have physician reports indicating TB results which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2023
	Plan of Correction
1 2 3 4	Licensee to obtain physician reports indicating TB results on the two clients and send CCL a copy of the physicians reports by 5/10/23.

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:

Darlene Chavez

LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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.-D.T.A.C.	FACILITY NUMBER: 405800568
	VISIT DATE: 05/03/2023

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LPA conducted a file review of 5 staff for criminal record clearances and associations, Health screening with TB results, current First Aid/CPR, and adequate training hours. Staff training records were present with 4 out of 5 staff annual training not completed and not meeting the minimum 20 hours of annual training. Deficiency cited. The facility’s Emergency Disaster Plan (LIC 610D) was not complete nor posted in the facility. Technical violation given. The facility has a complete first-aid kit on premises.

Exit interview, deficiencies cited, technical violations issued, and the report and appeal rights given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

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