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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800693
Report Date: 09/22/2022
Date Signed: 09/22/2022 01:48:36 PM


Document Has Been Signed on 09/22/2022 01:48 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:BAYWOOD MANOR RCFEFACILITY NUMBER:
405800693
ADMINISTRATOR:GUILLERMA PACAOANFACILITY TYPE:
740
ADDRESS:1489 11TH ST.TELEPHONE:
(805) 528-1455
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY:6CENSUS: 4DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Eddie Pacaoan, AdministratorTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) De Leon conducted an on site 1 year infection control annual visit to the facility above on 09/22/2022 at 12:50 PM. LPA met with Eddie Pacaoan
Licensee and explained the purpose of the visit.

Licensee 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 in the dining room where everyone entering completes sign-in, symptom questionnaire and temperature screening, hand hygiene and masking. All documentation is kept on file. The entry station has hand sanitizer along with a thermometer. The facility has signs posted through out the facility reminding social distancing, hand hygiene, reporting of symptoms. Activities have been modified to individuals or small groups with social distancing. The facility has several areas large enough to accommodate activities and exercise, all areas are spaced for social distancing. All PPE supplies are kept in filing cabinet in the dining area accessible to all staff. Medications are kept in a locked filing cabinet in the dining room. The kitchen area was clean, safe and sanitary, well stocked with perishable and non-perishable foods to meet the regulation requirements. The dining area is large enough to accommodate distancing between residents when eating meals, signs are posted to remind individuals of social distancing. The staff screen residents for symptoms and temperature 1x's a day and documentation is kept on file. Increased monitoring is conducted if any change of condition is noted with any resident. All required postings are hung in common areas of the facility. Facility provides residents with masks when leaving the facility on any outings into the community. Furniture has been moved around to accommodate social distancing for staff and residents. 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. Continued 809-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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: BAYWOOD MANOR RCFE
FACILITY NUMBER: 405800693
VISIT DATE: 09/22/2022
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Staff and resident records are kept in locked filing cabinets in the dining room. Facility is well stocked with cleaning supplies and disinfectants. The facility also offers virtual and telephone communications to residents in care. The facility has hand sanitizer located thorough out the facility. Staff, residents and visitors are informed of the facilities infection control policies. New staff and residents 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 is posted in the dining area and all agencies with telephone numbers are 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 when needed. Staff will use full PPE with N95 masks, face shields or googles when dealing with any pending or confirmed positive cases of Covid-19. The facility has 3 residents bedrooms and 2 resident restrooms for use. Restrooms are kept clean and well stocked with soap and paper towels, as well as signs are posted for hand washing. Signs are 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 had tight fitting lids. Facility has plans and is able to deliver medications and meals to any quarantined/isolation room. Facility Administrator's notifies proper agencies to report outbreaks or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/or 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. The laundry area is on covered patio out the front of residence which is kept clean and sanitary. Facility administrator and staff realize guidance changes frequently and the most up to date guidance and most stringent orders from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. LPA checked staff roster. Fire Extinguishers were charged and inspected annually.

Exit interview completed and copy of report emailed to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC809 (FAS) - (06/04)
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