405801055-3-8-2023-29-AS-RDLN-CPQU6D-20230308141810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801055
Report Date: 03/08/2023
Date Signed: 03/08/2023 02:19:09 PM

Document Has Been Signed on 03/08/2023 02:19 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 II		FACILITY NUMBER:	405801055
ADMINISTRATOR:	GUILLERMA M.PACAOAN		FACILITY TYPE:	740
ADDRESS:	1090 PASO ROBLES AVENUE		TELEPHONE:	(805) 528-5305
CITY:	LOS OSOS	STATE: CA	ZIP CODE:	93402
CAPACITY:	6	CENSUS: 4	DATE:	03/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Wilfred "Eddie" Pacaoan, Licensee		TIME COMPLETED:	02:25 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’s (LPA’s) De Leon and Chavez arrived at 9:45 am and made an unannounced 1-year required annual visit to the facility above. LPA’s met with Wilfred Pacaoan, Licensee and explained the purpose of the visit. LPA’s requested a staff roster, a resident roster, emergency disaster plan, documentation of quarterly emergency drills. LPA’s provided administrator the entrance checklist and asked for a physical plant tour. A tour of the physical plant was assessed, and the following was noted: LPA observed the license posted, personal rights, LTCO poster, CCL Complaint poster and covid signs. The facility has 3 bedrooms with 2 bathrooms, kitchen, living room, dining room, laundry room, medications locked in files in living room, covered patio with chairs for resident outside use. Physical plant was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, and all were in good condition. The facility maintains a comfortable temperature. The facility provides working telephones and on-line communication for resident use. The smoke detectors are hard wired, tested and working properly. The carbon monoxide detector was tested and operational. Fire extinguishers were last inspected 08/19/2022 and all show charged in the green. There are no issues with Fire Clearance. Living and dining rooms furniture were also checked for functionality and condition. The living rooms was clean, safe and sanitary along with the dining rooms.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

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 II	FACILITY NUMBER: 405801055
	VISIT DATE: 03/08/2023

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There are no bodies of water on the premises. The facility had buckets of water that LPA requested to be emptied. There is plenty of lighting available for the safety of the residents. The kitchen area was sufficiently stocked with two-day perishable and seven-day non-perishables. The following needed cleaning kitchen oven, stove, cupboards. The facility did not have a sample menu to review. Snacks and beverages are available for residents in the facility when they want. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. The kitchen has two unlocked gates making the stove in accessible to dementia residents in care.
The Resident rooms have beds with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and enough lighting for each resident. Residents arranged the rooms the way they want them. There is enough linen available to change weekly or more if need.
The bathrooms were checked for cleanliness and proper operation. The hot water temperature measured at 116.3 F in bathroom #1 and bathroom #2 at 120.0 F. Towels and washcloths are not shared. Residents have a sufficient amount of supplies for personal hygiene. Soap and Toilet paper are provided by the Licensee. Grab bars are secured in toilet and shower areas. Showers have non-slip mats.
Resident records were reviewed for requirements and legibility: LPA reviewed 4 resident’s files for current Medical Assessments with TB results, Current Appraisal Needs and Service plans which were not updated, signed Admission Agreements, consent forms, and immunization records. Planned activities are offered to residents in care.
Infection control was evaluated and facility is in compliance.
The facility needs to fix outside gates to be self- closing and self latching, a gate needs to be added between the deck and fence on the side of the home to make the very back yard inaccessible to residents s it is used for storage.
Facility sketch will need to be updated for legibility of licensed areas, staff office is no longer used for that purpose and has been designated for staff area.
Hall closet and garage door needs to be kept locked inaccessible to dementia residents as cleaning supplies are stored in it. The facility has recently painted and new vents need to be hung back up. The outside yards need to be cleaned up and tools moved to storage area inaccessible to dementia residents.

LPA's will return at a later date to review staff files, medications, staff training and interviews of staff and residents to complete the annual.

Exit interview conducted, Technical Violations issued, 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: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC809 (FAS) - (06/04)

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