405800577-7-14-2023-29-AS-DCHZ-CTQUSD-20230714155009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800577
Report Date: 07/14/2023
Date Signed: 07/14/2023 03:50:48 PM

Document Has Been Signed on 07/14/2023 03:50 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:	VILLAGE AT SYDNEY CREEK, THE		FACILITY NUMBER:	405800577
ADMINISTRATOR:	KIRK P KLOTTHOR		FACILITY TYPE:	740
ADDRESS:	1234 LAUREL LANE		TELEPHONE:	(805) 543-2350
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	84	CENSUS: 66	DATE:	07/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:43 AM
MET WITH:	Kirk Klotthor, Administrator		TIME 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	On 7/14/23 at 10:43 am, Licensing Program Analyst (LPA) Chavez made an unannounced Annual/Required visit to the facility above. LPA met with Kirk Klotthor, Administrator, and explained the purpose of the visit. A tour of the physical plant was assessed, and the following was noted: LPA observed the license posted, Complaint Poster, Bill of Rights and Right to Residential Council, non-discrimination statement, and resident rights. The facility conducted Emergency Disaster Drills on 3/21/23, 8/2/22, and 8/8/22, however, drills were not conducted quarterly as required. Deficiency cited. Physical plant was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, all in good condition with the exception of one window screen in Neighborhood 1 which was torn. Licensee will repair or replace and send a photo to CCL by 7/21/23 showing the correction. The facility maintains a comfortable temperature. The smoke detectors are hard wired and carbon monoxide detectors are placed in each neighborhood near the kitchenettes. Fire extinguishers are located throughout the facility, they were inspected on 04/21/23 and are charged in the green. There was one fire extinguisher, labeled as #19, which was not in the green, but rather the indicator was in the red to the left of the green. Licensee will get this inspected and send a photo to CCL by 7/21/23. There are no issues with Fire Clearance. Living rooms, dining rooms, and activity room furniture were checked and in good condition. The common rooms are clean, safe and sanitary. The courtyards of the facility have outdoor furniture, with shaded area for residents. Fountains are in compliance. Continued on 809-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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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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: VILLAGE AT SYDNEY CREEK, THE	FACILITY NUMBER: 405800577
	VISIT DATE: 07/14/2023

NARRATIVE

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The kitchen area was sufficiently stocked with two-day perishable and seven-day non-perishables. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. The kitchen has three garbage cans, and two did not have lids. Licensee will place lids on the trash cans and send CCL photos by 7/21/23. No flies or pests were observed in the kitchen. Refrigerators are kept at 40 F or below and the freezer at 0 F degrees.
Resident rooms are adequately supplied with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and sufficient lighting for each resident. There is enough linen available to change weekly or more, if needed.
Activity Room has sufficient activities for residents to stay active. At 11:50 am, LPA entered an open door to the kitchenette in the Activity Room and observed more than 5 pair of scissors in an unlocked drawer. Administrator immediately placed them in a locked drawer and will leave them there or add a lock to the "Office Supplies" drawer where they were observed. Technical violation issued.
The Storage Rooms have sufficient amounts of personal hygiene products which are provided by the licensee and all cleaning products, toxins are stored and locked away inaccessible to residents in care.
The bathrooms were checked for cleanliness and proper operation. The hot water temperature measured between 110.3 F and 112.0 F degrees in resident rooms 104, 111, 209, 212, 301, and 308.
Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for Medical Assessments, Needs and Service plans, Signed Admission Agreements and Pre-appraisals. There were no issues with resident files reviewed. Planned activities are offered to residents in care.
Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations/and current First Aid. Three staff have not completed the required first aid certification. Licensee will ensure staff complete this and send a copy to CCL by 7/21/23. The Administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate. Staff #1 (S1) was not associated with the facility during their entire time working in the facility. This poses an immediate health and safety risk to residents in care. Deficiency cited.

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

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/14/2023 03:50 PM - It Cannot Be Edited

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: VILLAGE AT SYDNEY CREEK, THE	FACILITY NUMBER: 405800577
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 4 training drills which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/21/2023
	Plan of Correction
1 2 3 4	Administrator has created a new program to ensure quarterly drills are completed on-time. Administrator will implement this immediately. No further action needed at this time.

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	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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