405800693-9-19-2024-29-AS-MRAN-D99STQ-20240919140954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800693
Report Date: 09/19/2024
Date Signed: 09/19/2024 02:10:10 PM

Document Has Been Signed on 09/19/2024 02:10 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BAYWOOD MANOR RCFE		FACILITY NUMBER:	405800693
ADMINISTRATOR:	GUILLERMA PACAOAN		FACILITY TYPE:	740
ADDRESS:	1489 11TH ST.		TELEPHONE:	(805) 528-1455
CITY:	LOS OSOS	STATE: CA	ZIP CODE:	93402
CAPACITY:	6	CENSUS: 3	DATE:	09/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Maria Edna Alvarado		TIME COMPLETED:	02:15 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) Rankin arrived at 9:50 am to conduct a 1 year annual visit to the facility above. LPA met facility Designee Maria Edna Alvarado and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Designee. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan on file with the department. The facility has a sign in and out binder at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30-day supply of PPE which they share with sister facility next door. 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). 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 has current liability insurance and expires on 02/23/2025. The facility is approved for a capacity of 6 non-ambulatory of which 1 may be bedridden in bedroom #1 and a Hospice waiver for 3. The facility is an RCFE approved for dementia residents. Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BAYWOOD MANOR RCFE	FACILITY NUMBER: 405800693
	VISIT DATE: 09/19/2024

NARRATIVE

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Physical Plant & Environmental Safety: The facility has 4 bedrooms and 2 bathrooms currently occupying 3 residents and employs 6 staff. One of the bedrooms is designated for live in staff. LPA was authorized to enter and inspect facility. The facility living room, dining room, bedrooms, and bathrooms were clean, safe, and sanitary. The facility has smoke and carbon monoxide detectors. Carbon monoxide and smoke alarm was tested and working at the time of the visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort and safety. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in cupboards in the bathroom and office. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard and front yard for client use with a patio for shade. The facility has telephone and internet service for resident use. Right front gate needs a new latch for ease to remain self-closing and self-latching.

Staffing: The facility employes 5 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 4 random staff files and Administrator file. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. All files were kept up to date with all requirements being met.

Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements, PPE and Quarterly Disaster Drills. Staff handling medications had required medication training. Trainer met the requirements to train staff. Initial training was kept on file. Additional training will be done with administrator for completing all annual hours.

Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BAYWOOD MANOR RCFE	FACILITY NUMBER: 405800693
	VISIT DATE: 09/19/2024

NARRATIVE

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Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Three files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The Facility does not handle cash resources for the residents in care. Facility does submit incident reports to the department when required.

Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Non-Discrimination notice and Theft and Loss policy. CCL Complaint poster was 20x26 in size and posted in the common area of the facility. The LTCO poster was posted in the common area dining room as well as the current license. The facility has the last CCL report and CCL PIN posted.

Planned Activities: The facility offers activities to all residents in care. The facility offers activities to include books, magazines, newspapers, television, walks, group discussions and communications, games, and puzzles. The facility has sufficient space to allow for activities indoors and outdoors.

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. Food is mainly prepared at sister facility and brought to current facility. Food, snacks, and drinks are available when the residents want them. Emergency supply of food is available, more emergency water will be purchased to stock the supply. Cleaning solutions and equipment are stored separately from food supplies. Kitchen area under the sink has a leak. Will follow-up with facility on progress of repair. The kitchen is free from litter, rodents, vermin, and insects.

Incidental Medical & Dental: The facility has locked medication file cabinets in the dining-room. Facility provides transportation to medical and dental appointments when needed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BAYWOOD MANOR RCFE	FACILITY NUMBER: 405800693
	VISIT DATE: 09/19/2024

NARRATIVE

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A sampling of medications records were reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected medication cabinets for all prescription and PRN medications and Doctors orders. No medications labels were altered or expired. The facility has a locked small refrigerator for required medication and an ice chest with ice packs to keep cold for emergency use.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 07/18/2024. 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.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or inaccessible to residents in care. The facility does not currently have residents with oxygen. The facility does not have delayed egress. The facility has exiting door alarms in all exiting doors.

Exit interview conducted, copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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