405801226-6-22-2023-29-AS-RDLN-CSXVRN-20230619164014

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801226
Report Date: 06/19/2023
Date Signed: 06/22/2023 09:23:50 AM

Document Has Been Signed on 06/22/2023 09:23 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	JAJ RESIDENTIAL CARE FOR ELDERLY		FACILITY NUMBER:	405801226
ADMINISTRATOR:	JOE D. CASTILLO		FACILITY TYPE:	740
ADDRESS:	517 LOS OSOS VALLEY ROAD		TELEPHONE:	(805) 528-7740
CITY:	LOS OSOS	STATE: CA	ZIP CODE:	93402
CAPACITY:	6	CENSUS: 5	DATE:	06/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Joe Castillo, Administrator		TIME COMPLETED:	05:00 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 12:00 pm to conducted a 1 year annual visit to the facility above. LPA met with Licensee/Administrator Joe Castillo 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 submitted a current Mitigation Plan, Infection Control Plan, Emergency Disaster Plan and provided plans to the department. The facility has a sign in and out binder for visitors at entry with hand sanitizer and symptom screening. 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. New residents are tested and negative results received before residing in the facility. 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). All trash cans and waste baskets have tight fitting covers. Physical Plant & Environment Safety: The facility is a 5 bedroom and 2 bathroom currently occupying 5 residents and employs 5 staff with 2 live-in staff using 1 bedroom and 1 bathroom. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has a carbon monoxide detector and smoke alarms. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The showers have non-skid textured floors. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions and well lit. Disinfectant, cleaning solutions and poisons are locked and inaccessible to residents in care. The facility has sufficient space inside and outside for activities and visiting. The facility has telephone and internet service for resident use. Operational Requirements: The facility has a current plan of operation and infection control plan 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 06/15/2024. The facility is approved for a capacity of 6 Non-Ambulatory and has a current Hospice wavier granted for 1.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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: JAJ RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 405801226
	VISIT DATE: 06/19/2023

NARRATIVE

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Staffing: The facility employes 4 staff and 1 Administrator. Staff records are kept confidential. Staff files were not reviewed on this visit and will be done on the annual continuation visit.

Personnel Records & Training: Staff files and training records were not reviewed on this visit and will be reviewed on the annual continuation visit.

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 excepting them into care. The Facility does not handle cash resources for any resident in care. Facility does submit incident reports to the department when required. 1/5 Admission Agreements were missing, 4/5 ANS were not up to date. 2/5 needed TB result on file. Administrator will send copies of missing forms to LPA after retrieving additional files from off site office.

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 along with CCL reports and PIN's were posted. Visitation policy is posted at entry. The facility has a working telephone for resident use. Internet is provided with confidentiality and privacy for each resident.

Planned Activities: The facility offers activities to all residents in care. The facility has a monthly calendar with all activities posted. The facility also offers additional activities to include books, magazines, newspapers, television, group discussions and communications, games and puzzles. The facility has sufficient space to allow for activities indoors and outdoors.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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: JAJ RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 405801226
	VISIT DATE: 06/19/2023

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. Emergency supply of food and water is available. A menu is posted for residents in care. Modified diets prescribed by a physician are followed for those residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices.

Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed for the Centrally Stored Medication and Destruct Records (CSMDR) and Medication Administrator Records (MAR). Records were up to date, legible and given as prescribed. LPA completed a full audit on two residents medications, all medications were in original containers, prescription labels were not altered, doctors orders were present and dispensing instructions were followed.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills no documentation was present, Licensee will provide LPA records of quarterly drills. The fire extinguishers were charged and last inspected 02/22/2023. 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 and a file with residents emergency information is present for each resident in care.

Residents with Special Health Needs: All items that could pose a danger, sharps, cleaners were locked and in accessible to residents in care. The facility does not have delayed egress. The facility has 1 hospice residents in care. Hospice care plan was missing in resident file and Licensee will provide a copy to LPA once retrieved from off site office. The facility does not currently have residents on any Home Health services.

LPA will return at a later date to complete annual for staff records, staff training and interviews.

Exit interview conducted and copy of report printed for Licensee/Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

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