405800568-5-22-2025-29-AS-RDLN-DGWUVG-20250522155507

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800568
Report Date: 05/22/2025
Date Signed: 05/22/2025 03:55:24 PM

Document Has Been Signed on 05/22/2025 03:55 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.-ACTIVE LIFE CENTER		FACILITY NUMBER:	405800568
ADMINISTRATOR/ DIRECTOR:	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:	05/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Regina Ceasar, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:00 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 1:00pm to conducted a 1 year annual visit to the facility above. LPA met with Administrator Regina Ceasar 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 Adult Day Program (ADP) has submitted a current Infection Control Plan to the department. The facility has a sign in and out binder for visitors at entry. 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 be picked up from program. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environmental Safety: The facility has 2 buildings multiple rooms with an activity room, 1 staff office room, kitchen & medication room, and 4 restrooms, the facility is currently occupying 26 clients and employs 20 staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting is sufficient for the use of the facility and for clients comfort. The facility kitchen is clean, safe and sanitary. Toilet and hand washing facilities are operational. The pathways are clear of any obstructions. Disinfectant, cleaning solutions and poisons are inaccessible to clients in care locked in supply closet near the kitchen. The facility has sufficient space inside and outside for activities and visiting. The facility has telephone and internet service for clients. Water temperatures were checked and within regulation requirements. Continued 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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.-ACTIVE LIFE CENTER	FACILITY NUMBER: 405800568
	VISIT DATE: 05/22/2025

NARRATIVE

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Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 45 with 45 being Ambulatory clients.

Staffing: The facility employes 19 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, Administrator file was reviewed for education training hour requirements.

Personnel Records & Training: The facility keeps confidential files for each staff member. 5/5 staff had current 1st AID/CPR, Records were present, up to date and kept confidential. Initial and Annual Training requirements are being met. All staff files had 20 plus hours of Annual training from 06/2024-05/2025. CPI cards are present in each file and all were current.

Clients Rights: All require postings were posted in the common area of the program. Personal rights and Persons with disabilities are posted in the common areas of the program. The current license 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 clients confidentially. Five 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's and ISP's completed quarterly and annually, TB results, and Personal Rights. The facility does not handle cash resources. Facility does submit incident reports to the department when required.

Food Service: The ADP has a kitchen on the premises. Lunches are brought to program by clients. The facility handles and prepares food safely. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees. All food is covered, stored and marked appropriately. ADP offers snacks to all clients in care. 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. Drinking water is available to all clients.

Continued 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

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.-ACTIVE LIFE CENTER	FACILITY NUMBER: 405800568
	VISIT DATE: 05/22/2025

NARRATIVE

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Health Related Services: Facility provides Centrally Stored Medications to clients in care. First Aid is provided to clients in care. Clients medication records were reviewed, prescriptions and PRN medications were checked for expiration dates, medications stored in original containers, and no labels were altered. All medications are locked in the medication area in a cart.

Incidental Medical Services: The ADP contacts clients responsible parties for medical and dental services. The ADP uses the Medication Administration Record (MAR) and the Centrally Stored Medication and Destruct Record (CSMDR) for clients taking medication at program.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts disaster drills every 6 months. The fire extinguisher was charged and last inspected 06/2025. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full program in an emergency.

Emergency Intervention: The facility does not use manual restraint or seclusion on any clients in care. The facility does have staff take CPI training. All staff had current CPI Cards.

LPA conducted interviews with 2 Staff and no Client interviewed due to being out in community or went home for the day.

Exit interview conducted, copy of report printed for Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC809 (FAS) - (06/04)

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