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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800703
Report Date: 12/28/2023
Date Signed: 01/03/2024 10:20:48 AM

Document Has Been Signed on 01/03/2024 10:20 AM - 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:OPTIONS - CIS - ATASCADEROFACILITY NUMBER:
405800703
ADMINISTRATOR:CHRISTINA HUTCHISONFACILITY TYPE:
775
ADDRESS:5185 EL CAMINO REALTELEPHONE:
(805) 462-0550
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 25CENSUS: 12DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Verneda Robinson - SupervisorTIME COMPLETED:
11:45 PM
NARRATIVE
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At 7:30am on 12/28/2023, Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility unannounced to conduct the annual inspection visit. LPA met with Program Supervisor Vernedea Robinson and explained the reason for the visit.
LPA toured the facility with the Supervisor, facility The facility is maintained in conformance with state fire marshal regulations. Smoke detectors and carbon monoxide detectors functioning. Fire extinguisher is fully charged. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. There is covered patio area with shade for the clients outside. The facility temperature was 70 degrees F. Hot water temperature tested within regulations of 105*-120*(f). A written disaster and mass casualty plan is readily available located on the facilities office wall. Clients are also serviced through Tri-Counties Regional Center and meet at the facility in the AM then conduct their program at various locations throughout the community. The staff to client ratio is 3:1. The facility has first aide kit per regulations. Facility records, client records are located at this facility, staff records are located at a San Luis Obispo location, however LPA was able to review current working staff annual training hours. Training records were located in training log and LPA could not ascertain personnel files had training logs in those files and a Technical Advisory was issued. LPA and Supervisor discussed potential resolutions for files. LPA reviewed medications. Medications are stored in a locked cabinet. LPA observed the Centrally Stored Medication Record (CSMR) and medications are given per physician's orders.
Supervisor and LPA conducted a full review of annual control tools module.

Exit interview, deficiency cited, report and appeal rights provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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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Document Has Been Signed on 12/28/2023 11:36 AM - It Cannot Be Edited


Created By: Mark Jeffries On 12/28/2023 at 11:30 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OPTIONS - CIS - ATASCADERO

FACILITY NUMBER: 405800703

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
82066(c)
Personnel Records
(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Mark Jeffries
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023


LIC809 (FAS) - (06/04)
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