405800830-1-12-2024-29-AS-RDLN-CZEUU9-20240112145312

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800830
Report Date: 01/12/2024
Date Signed: 01/12/2024 02:54:00 PM

Document Has Been Signed on 01/12/2024 02:54 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:	AMERICAN CARE HOME		FACILITY NUMBER:	405800830
ADMINISTRATOR:	LIXIA ZHANG		FACILITY TYPE:	735
ADDRESS:	1240 EL CAMINO REAL		TELEPHONE:	(805) 466-9029
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY: 38		CENSUS: 33	DATE:	01/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lixia Zhang, Administrator		TIME COMPLETED:	03:00 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	Licensing Program Analyst (LPA) De Leon arrived at 9:30am to conducted a 1 year annual visit to the facility above. LPA met with Licensee/Administrator Lixia Zhnag and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Infection Control Plan to the department. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, and hand soap. 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). All trash cans and waste baskets have tight fitting covers. Physical Plant & Environmental Safety: The facility is a 19 bedroom with 6 shared resident bathrooms, 4 common area bathrooms and 1 staff bathroom, currently occupying 33 residents and employs 13 staff with 2 being Administrators. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen is clean, safe and sanitary. Toilet, hand washing and bathing facilities are operational. 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 storage rooms. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard and courtyard for resident use with plenty of shade. The facility has telephone and internet service for resident use. Water temperatures were tested and within regulation requirements. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMERICAN CARE HOME	FACILITY NUMBER: 405800830
	VISIT DATE: 01/12/2024

NARRATIVE

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Operational Requirements: The facility has a current plan of operation with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity 38 with Ambulatory and 2 Non-Ambulatory.

Staffing: The facility employes 17 staff and 2 Administrators. Staff records are kept confidential. LPA reviewed 5 staff files for 1st AID/CPR, Finger print clearances, Applications, Health exam with TB results, and Criminal Record statements.

Personnel Records & Training: The facility keeps confidential files for each staff member. Five staff files were reviewed and had current 1st AID/CPR training as well as the Initial and Annual Training, Residents Personal Rights, current residents needs and services plan, emergency preparedness training, PPE and Infection Control Plan and any staff handling medication has medication training.

Clients Rights: All require postings were posted in the common area of the facility. Personal rights, CCL Complaint poster is posted. The current license along with CCL reports and PIN's were printed in folders for review,and visitation policy is posted at entry. Internet is provided to each client and each client is given confidentiality and privacy.

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 45 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. A menu is posted for residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices.

Clients 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 TB results, Personal Rights, and Safeguard for personal property and valuables. The Facility does handle cash resources for residents in care. LPA audited 3 residents funds with ledgers, cash, receipts, and all balancing. The facility Surety bond is current. Facility does submit incident reports to the department when required. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

LIC809 (FAS) - (06/04)

Page: 2 of 31

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: AMERICAN CARE HOME	FACILITY NUMBER: 405800830
	VISIT DATE: 01/12/2024

NARRATIVE

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Health Related Services: Facility provides Centrally Stored Medications to all residents in care. First Aid is provided to residents in care. Residents medication records were reviewed, prescriptions and nonprescription PRN had doctors orders. Medications, PRN medications and Over the counter medications were checked for expiration dates, labels were not altered, all were stored in their original containers and no issues were found.

Incidental Medical Services: Facility assist in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) and the Centrally Stored Medication and Destruct Record (CSMDR).

Disaster Preparedness: The old form was posted. Licensee is completeing the update form and will send copy of the updated form to CCL. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 02/12/2023. 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.

Emergency Intervention: The Facility does not use restraints or seclusion and does not conduct the CPI Non-Violent Crisis Intervention Training.

LPA conducted interviews with 3 staff and 3 residents.

Exit interview conducted and copy of report printed for Licensee/Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

LIC809 (FAS) - (06/04)

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