405801050-12-10-2021-29-AS-RDLN-C9KQJ6-20211210111214

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801050
Report Date: 12/10/2021
Date Signed: 12/10/2021 11:12:41 AM

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:	FIVE CITIES RESIDENCE		FACILITY NUMBER:	405801050
ADMINISTRATOR:	PATACSIL, CAROLINA G.		FACILITY TYPE:	740
ADDRESS:	472 DIXSON STREET		TELEPHONE:	(805) 489-3481
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	6	CENSUS: 4	DATE:	12/10/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Abraham Garces, Back up Administrator		TIME COMPLETED:	11:25 AM

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 conducted an on site 1 year infection control annual visit to the facility above on 12/10/2021 at 10:10 AM. LPA met with Backup Administrator Abraham Garces and explained the purpose of the visit. LPA took a physical plant tour of the facility. The facility has submitted a mitigation plan to the department and it has been approved. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening on all staff, residents returning to the facility and visitors wanting to come into the facility. All documentation is kept on a clipboard. The entry station has hand sanitizer along with a thermometer. The facility has a large living room to accommodate activities, a dining room for dining, all areas are spaced to accommodate as much space as possible for social distancing. All equipment and PPE supplies are kept at entry point and extra is kept in garage, all accessible to staff. Medications are kept in a locked medication cabinets in dining area. The staff screen residents for symptoms and temperature 1x's a day and documentation is kept on file. Increased monitoring is conducted if any change of condition is noted or any residents is showing any signs, symptoms or has a temperature. Signs are posted on the walls through out the facility regarding Covid-19 symptoms to report to staff, coughing and sneezing etiquette, hand hygiene, mask wearing, social distancing, and PPE donning/doffing. All required postings are hung at entry point and in common areas of the facility. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility have areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. 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: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

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: FIVE CITIES RESIDENCE	FACILITY NUMBER: 405801050
	VISIT DATE: 12/10/2021

NARRATIVE

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The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility a certain staff will be assigned to only work with those quarantined/isolated individuals and will not work with other negative individuals until cleared by Health Department to do so. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. The facility has 2 resident restrooms for resident use and they are disinfected after use. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room. The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff and residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in locked cabinet in the office area. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies.
No deficiencies observed during the visit and all infection control protocols are implemented and are being followed.

Exit interview completed and copy of report emailed to Administrator/Licensee.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

LIC809 (FAS) - (06/04)

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