405801055-5-29-2024-29-AS-EMIR-D5QS5F-20240529133418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801055
Report Date: 05/29/2024
Date Signed: 05/29/2024 01:34:39 PM

Document Has Been Signed on 05/29/2024 01:34 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
WOODLAND HILLS N.ASC, 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:	05/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Guillerma Pacoan, Administrator		TIME COMPLETED:	01:43 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) Miller arrived at 9:11 am and made an unannounced 1-year required annual visit to the facility above. LPA met with Guillerma M. Pacaoan, Administrator 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 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 sprays 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). Physical Plant & Environment Safety: The fire extinguisher were last charged and inspected on July 18, 2023. All trash cans and wastebaskets have tight fitting covers.The facility is a 3 bedroom and 2 bathroom, currently occupying 4 residents. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors that were tested. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions are inaccessible to residents in care locked and stored in the laundry room and or locked under kitchen sink. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BAYWOOD MANOR RCFE II	FACILITY NUMBER: 405801055
	VISIT DATE: 05/29/2024

NARRATIVE

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Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance and expires on February 3, 2025. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 6. The fire clearance is granted for 5 non-Ambulatory, 1 bedridden resident in bedroom #1 only, and has a hospice waiver for 1. Facility currently has 3 non-Ambulatory and 1 hospice resident.

Staffing: The facility currently employs 4 full time staff, 3 back-up staff, and 1 administrator. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate is active on the certification list. Administrator Certificate expires October 16, 2025.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2023 and 2024.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 4 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible, and records are kept confidential.

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. Cleaning solutions and equipment are stored separately from food supplies.
Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BAYWOOD MANOR RCFE II	FACILITY NUMBER: 405801055
	VISIT DATE: 05/29/2024

NARRATIVE

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Incidental Medical Services: Facility provides transportation or assists 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). LPA reviewed residents’ medications, no medications were expired, and all medications were kept in their original containers.

Disaster Preparedness: The current emergency disaster forms were posted. The Facility last conducted a quarterly disaster drill April 1, 2024. 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.

Residents with Special Health Needs: The Facility does accept dementia residents in care. The facility has 2 self-latching gates on side of the home, used to exit Facility. The Facility does not have delayed egress, locked doors or gates. Exit door alarms are working.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC809 (FAS) - (06/04)

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