405801283-6-15-2021-29-AS-MJES-C3ZP4C-20210615105856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801283
Report Date: 06/15/2021
Date Signed: 06/15/2021 10:59:54 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:	ALDER HOUSE		FACILITY NUMBER:	405801283
ADMINISTRATOR:	TODD TOSE		FACILITY TYPE:	740
ADDRESS:	295 ALDER STREET		TELEPHONE:	(805) 489-1266
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	32	CENSUS: 20	DATE:	06/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	JoAnn Bazer/Licensee		TIME COMPLETED:	12:15 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	At 8:30am, Licensing Program Analyst (LAP) Mark Jeffries made contact by telephone with JoAnn Bazer (Licensee) to conducted the Infection Control Module screening questions. Telephone call indicated that no COVID-19 positive or symptoms present at the facility. At 8:35am LPA arrived at the facility and met with the Licensee. Licensee and LPA conducted a tour of the facility. The facility consist of 23 bedrooms, 23 bathrooms, 2 common areas, dining room and kitchen. There is an outside courtyard in the middle center of the facility and a side courtyard to south side of the building. Each room has its own bathroom and each room has an exit to the outside. There is a chicken coup and garden in the back of the facility and a garage and storage area on the north side of the facility. LPA observed seven days of perishable and two days of non-perishable food. LPA observed all fire extinguishers recently serviced and in the green area of the charge gage. At 10:25am LPA and License check the water temperature in bathroom for room 7 tested at 124* degrees with three different thermometers to ensure accurate reading, LPA assessed a violation of regulation 87303(e)(2) for water temperature. Licensee instructed facility co-owner to immediately adjust water temperature on water furnaces to comply with title 22 regulations. Licensee and LPA reviewed Infection Control Module of Annual inspection. No other deficiencies found during tour. Exit interview, deficiency cited. appeal rights given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

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: ALDER HOUSE	FACILITY NUMBER: 405801283
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	87303 (e)(2) Maintenance and Operation(e) Water supplies and plumbing fixtures shall be maintained as follows:(2)Faucets used by residents ... shall deliver hot water. Hot water ... used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This regulation was not met as evidence of
	POC Due Date: 06/22/2021
	Plan of Correction
1 2 3 4	three different temperature readings of 124* at 10:25am. which poses an immediate risk to residents in care. License will adjust water heater temperature and check water tempature twice daily for one week, then repot temperature adjustment to LPA by email.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

LIC809 (FAS) - (06/04)

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