405801057-2-13-2024-29-AS-EMIR-D2EMVR-20240213085708

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801057
Report Date: 02/12/2024
Date Signed: 02/13/2024 08:57:44 AM

Document Has Been Signed on 02/13/2024 08:57 AM - 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:	BAY OSOS RCFE I		FACILITY NUMBER:	405801057
ADMINISTRATOR:	RODOLFO PACAOAN		FACILITY TYPE:	740
ADDRESS:	1663 13TH STREET		TELEPHONE:	(805) 528-4416
CITY:	LOS OSOS	STATE: CA	ZIP CODE:	93402
CAPACITY:	6	CENSUS: 3	DATE:	02/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	Rodolfo Pacaoan, Administrator		TIME COMPLETED:	03:52 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) Erika Miller arrived at 3:50 p.m. to conduct a one-year annual visit to the facility above. LPA Miller met with Administrator Rodolfo Pacaoan 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: Physical Plant & Environment Safety: The facility has 3 resident bedrooms, 1 caregiver bedroom and 2 bathrooms. Facility currently occupies 3 residents and employs 6 full time staff, 4 part time staff and three Administrators. LPA Miller was authorized to enter and inspect facility. The facility had a smoke and carbon monoxide detector that was tested and working properly during visit. 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 and poisons are inaccessible to residents in care locked in cabinet in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use and front patio has plenty of shade. The facility has telephone and internet service for resident use. Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance and expires on November 3, 2024. The facility is approved for a capacity of six. The fire clearance is granted for 6 non-Ambulatory of which one may be bedridden. Hospice is approved for three. (Continued on LIC 809-C)

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BAY OSOS RCFE I	FACILITY NUMBER: 405801057
	VISIT DATE: 02/12/2024

NARRATIVE

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Staffing: The facility currently employes 6 full time staff, 4 part time staff and three Administrators. Staff files were reviewed. Current Administrator Certificate expires January 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.

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 five resident files for signed Admission Agreements.

Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables and plenty extra, 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 staff are observed for personal hygiene and food sanitation practices.
Disaster Preparedness: The current emergency disaster forms were posted. 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 does not currently have residents receiving Home Health services. Exit door alarms are working.

Exit interview conducted, copy of report provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC809 (FAS) - (06/04)

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