405801283-6-14-2023-29-AS-RDLN-CSSW5B-20230614165852

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801283
Report Date: 06/14/2023
Date Signed: 06/14/2023 04:59:00 PM

Document Has Been Signed on 06/14/2023 04:59 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:	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: 21	DATE:	06/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Todd Tose, 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 10:00 am to conducted a 1 year annual visit to the facility above. LPA met Administrator Todd Tose 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 provide 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 trash bins with covers. 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 23 bedroom and 23 bathroom currently occupying 21 residents and employs 20 staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has a carbon monoxide detector, smoke alarm and sprinkler system. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen has a tap with hot water and warning sign is posted. The showers have non-skid textured floors. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The facility has a signal system in each residents room. The pathways are clear of any obstructions, well lite and equipped with hand railings where needed on ramps and porches. Fire places has screened coverings. Disinfectant, cleaning solutions and poisons are inaccessible to clients 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 02/02/2024. The facility is approved for a capacity of 32 Non-Ambulatory and has a current Hospice wavier granted for 6.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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: ALDER HOUSE	FACILITY NUMBER: 405801283
	VISIT DATE: 06/14/2023

NARRATIVE

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Staffing: The facility employes ____ staff and 1 Administrator. Staff records are kept confidential. Staff records were reviewed for 5 staff and 1 Administrators. Staff records had finger print clearance and associations with criminal record statements, personnel record or applications, First Aid and CPR certificates and Health screening with TB results. Facility employs sufficient and competent staffing for resident care, cooking, housekeeping, office work and maintenance of building and grounds. The facility has sufficient night staff on duty. Staff are trained to effectively interact with emergency personnel and provide residents medical records to emergency responders. Administrator certificate expires 09/05/2023.

Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records which were current for 2023 initial /or annual training requirements. Staff have been fingerprinted with criminal record clearances or exemptions. Administrator meets continuing education requirements for renewal of administrator certificate. Trainers meet the education and experience requirements. Staff training documents have trainers name, address, phone numbers, topic or subject matters, times, dates and hours.

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.

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. Internet is provided in each resident room for confidentiality and privacy.

Planned Activities: The facility offers activities to all residents in care. The facility employs an Activities Director and a monthly calendar with all activities is posted. The facility also offers additional activities to include books, magazines, newspapers, television, daily walks, group discussions and communications, games and puzzles. The facility has a piano for resident use. The facility has sufficient space to allow for activities indoors and outdoors as well as an activity room.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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: ALDER HOUSE	FACILITY NUMBER: 405801283
	VISIT DATE: 06/14/2023

NARRATIVE

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Food Service: The facility employs food service staff. 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 one residents medication, 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. The fire extinguishers were charged and last 08/01/2022. 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 not accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have delayed egress. The facility does have residents with oxygen and required signs are posted. The facility has ____ hospice residents in care. Hospice care plans are kept on file and up to date. The facility does not currently have residents on any Home Health services.

LPA conducted interviews with 3 Residents and 3 Staff.

Exit interview conducted 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: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC809 (FAS) - (06/04)

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