405800693-9-14-2023-29-AS-RDLN-CVP3HA-20230914181537

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800693
Report Date: 09/14/2023
Date Signed: 09/14/2023 06:16:11 PM

Document Has Been Signed on 09/14/2023 06:16 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 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: 5	DATE:	09/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Guillerma Pacaoan, Administrator		TIME COMPLETED:	06:25 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 10:45 am to conducted a 1 year annual visit to the facility above. LPA met Administrator Guillerma Pacaoan and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. 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. 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). Administrator will replace trash cans and waste baskets that do not have tight fitting covers. 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 02/23/2024. 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. Physical Plant & Environmental Safety: The facility is a 4 bedroom and 2 bathroom currently occupying 5 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 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. 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. Facility is well lit inside and outside for safety. 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. The gates are in need of repair to remain self closing and self latching, Administrator ordered supplies and is having work done to fix the issue. Cont. 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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: BAYWOOD MANOR RCFE	FACILITY NUMBER: 405800693
	VISIT DATE: 09/14/2023

NARRATIVE

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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 Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. 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 Initial 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.

Resident Records & Incident Reports: The facility keeps separate files on each resident 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), 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. A smaller version of the poster is posted at the front door. 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, daily walks, group discussions and communications, games and puzzles. The facility has sufficient space to allow for activities indoors and outdoors.

Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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: BAYWOOD MANOR RCFE	FACILITY NUMBER: 405800693
	VISIT DATE: 09/14/2023

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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. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas was in need of additional cleaning, administrator had staff clean and sanitize during LPA visit. The kitchen is free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices.

Incidental Medical & Dental: The facility has locked medication file cabinets in the dining-room. Facility provides transportation to medical and dental appointments when needed. The 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. The facility has a red sharps container for disposal of syringes. Medications destructed by Administrator and 1 other person by taking to Rexall Drugs. Hospice Medications are destructed by Hospice and witnessed by facility staff.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers was charged and last inspected 07/18/2023. 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 has 1 hospice residents in care. Hospice care plans are kept on file and up to date. The facility currently has 1 resident on Home Health services. Home Health services records are kept on file. The facility does not have delayed egress. The facility has exiting door alarms in all exiting doors.
LPA conducted interviews with 2 residents and 2 staff.

Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/14/2023 06:16 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: BAYWOOD MANOR RCFE	FACILITY NUMBER: 405800693
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(h)

Care of Persons with Dementia

(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3/3 gates were no longer self closing or self latching which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/21/2023
	Plan of Correction
1 2 3 4	Administrator orders new supplies to fix gates and called to have someone out to repair all 3 gates, once repaired will send video of each gate showing them self closing and self latching

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: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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