405800854-2-22-2024-29-AS-RDLN-D2PT23-20240222132003

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800854
Report Date: 02/22/2024
Date Signed: 02/22/2024 01:20:10 PM

Document Has Been Signed on 02/22/2024 01:20 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:	FULL CIRCLE RESIDENCE II		FACILITY NUMBER:	405800854
ADMINISTRATOR:	MANUEL, ROSITA		FACILITY TYPE:	740
ADDRESS:	483 NOEL ST.		TELEPHONE:	(805) 489-9658
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	6	CENSUS: 4	DATE:	02/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Rosita Manuel, Licensee/Administrator		TIME COMPLETED:	01:25 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 9:30 am to conducted a 1 year annual visit to the facility above. LPA met with Licensee/Administrator Rosita Manuel 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. The facility has a sign in and out binder for visitors 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 when and if needed. 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 & Environment Safety: The facility has 5 resident bedrooms, 1 resident bathroom, 1 common area bathroom and 1 bedroom for live-in staff, currently occupying 4 residents and employs 10 staff and 5 backup staff if needed. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. Carbon Monoxide detector was tested and alarmed properly. 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 are locked under the kitchen sink, locked under bathroom sink and in laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for resident use with plenty of shade. Telephone and internet services are provided for resident use. The facility has a working washer and dryer. 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: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

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: FULL CIRCLE RESIDENCE II	FACILITY NUMBER: 405800854
	VISIT DATE: 02/22/2024

NARRATIVE

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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 10/19/2024. The facility is approved for a capacity of 6 with 6 Non-Ambulatory, and Hospice is approved for 4.

Staffing: The facility employes 4 full time care staff, 1 Administrator, 2 maintenance staff, 2 back up Administrators and 6 part time/ on-call staff if needed. Staff records are kept confidential. LPA reviewed 5 staff files. 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, health screening with TB results, and current Administrator Certificate expired 11/23/2023, all renewal paperwork is pending with CCL, LPA verified Administrator on the pending list. Facility has two back up administrators and 1 administrator certificate expires 04/13/2025.
Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for Initial and Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training with all subjects covered over a 3 year period, 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, procedures, infection control, and PPE requirements. Quarterly Disaster Drills are completed. Staff handling medications had annual training. Trainers met the requirements to train staff with required information present in files. Hospice and Home Health had training records 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 any of 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, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license is posted. Visitation policy is posted at entry. Internet is provided to residents in care with confidentiality and privacy.
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: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

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

FACILITY NAME: FULL CIRCLE RESIDENCE II	FACILITY NUMBER: 405800854
	VISIT DATE: 02/22/2024

NARRATIVE

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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. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff were observed for personal hygiene and food sanitation practices.

Incidental Medical Services: Facility provides transportation or assist in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). Medications for all resident in care are centrally stored. LPA reviewed medications and records. No medications labels were altered and all medications were checked for expiration dates. Medication were given as prescribed by physicians orders.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. 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. Facility has emergency food and water supply, flash lights with batteries, and a cooler with ice packs for medications. The facility has two evacuation locations and a few places available for a back up generator if sheltering in place.

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 in accessible to residents in care. The facility has two self latching, self closing gates with alarms. The facility does have working exiting door alrams. The facility currently has 2 residents receiving hospice services. The facility currently has 1 resident receiving home health services. Hospice and Home Health care plans are kept on file and up to date. The facility does not currently have residents on oxygen. The facility does not have any delayed egress. There are no bodies of water on the premises.

LPA conducted interviews with 2 staff and attempted interviews with 4 residents.

Exit interview conducted and copy of report 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: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

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