405801389-8-5-2024-29-AS-MRAN-D7USPV-20240805140345

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801389
Report Date: 08/05/2024
Date Signed: 08/05/2024 02:03:55 PM

Document Has Been Signed on 08/05/2024 02:03 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:	OPTIONS FAMILY OF SERVICES-SONATA HOME		FACILITY NUMBER:	405801389
ADMINISTRATOR/ DIRECTOR:	FRAN WALKER		FACILITY TYPE:	735
ADDRESS:	5755 VALENTINA AVENUE		TELEPHONE:	(805) 462-8544
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY: 3		CENSUS: 2	DATE:	08/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Tammy Peterson, House Manager		TIME VISIT/ INSPECTION COMPLETED:	02:15 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	Licensing Program Analyst (LPA) Rankin arrived at 9:45 am to conduct a 1 year annual visit to the facility above. LPA met with Tammy Peterson, House Manager, 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 bathrooms have toilet paper, paper towels, and hand soap. The facility has EPA approved disinfectants spray and cleaners. The facility has a supply of PPE. 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 & Environmental Safety: The facility has 3 resident bedrooms with 1 shared resident bathrooms, and 1 private resident bathroom. There is an office with a staff restroom. Facility currently has 2 residents and employs a sufficient amount of staff to cover all shifts with 2 direct care staff per shift. The facility is clean, safe, and sanitary. The facility has smoke and carbon monoxide detectors, all but one was working, but a request for maintenance to change a smoke detector battery has been made for the one detector that wasn’t working in the living room area due to the high ceiling location. The lighting and lamps are sufficient for the use of the facility and for resident’s comfort. The facility kitchen is clean, safe, and sanitary. Toilet, hand washing and bathing facilities are operational. 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, they were found locked in the laundry room cabinets. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024

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: OPTIONS FAMILY OF SERVICES-SONATA HOME	FACILITY NUMBER: 405801389
	VISIT DATE: 08/05/2024

NARRATIVE

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The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for resident use with plenty of shade. Gates have working self-closing/self-latching mechanisms, one part of the fence is falling in, but a maintenance request was made to fix this area of the fence. The facility has telephone and internet service for resident use.

Operational Requirements: The facility has a current plan of operation with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 3 Ambulatory clients.

Food Service: The facility handles and prepares food. The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. 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. Cleaning solutions and equipment are stored separately from the food supply. Kitchen areas are kept clean and free from litter, rodents, and insects.

Clients Records & Incident Reports: The facility keeps separate files on each resident confidential. Two (2) files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans ,TB results, Personal Rights, and Safeguard for personal property and valuables. The Facility currently handles cash resources for one resident in care. LPA audited one (1) resident funds with ledgers, cash, receipts, and found all balancing. The facility Surety bond is current. Facility does submit incident reports to the department when required.

Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024

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: OPTIONS FAMILY OF SERVICES-SONATA HOME	FACILITY NUMBER: 405801389
	VISIT DATE: 08/05/2024

NARRATIVE

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Health Related Services: Facility provides Centrally Stored Medications to all residents in care. First Aid is provided to residents in care. Residents’ medication records were reviewed. Medications, PRN medications and over the counter medications were checked for expiration dates, labels were not altered, all were stored in their original containers and no issues were found. The facility uses the Medication Administration Record (MAR) and the Centrally Stored Medication and Destruct Record (CSMDR). Facility assists in providing transportation to medical and dental appointments when needed.

Disaster Preparedness: The facility and licensing agency has a disaster binder in place with all the necessary documents and requirements to support the facility and disaster plan. The facility conducts monthly disaster drills. The fire extinguishers were charged and last inspected 06/7/2024. Two sets of keys are available for staff on all shifts to access full facility in an emergency.

LPA conducted interviews with 1 staff and 1 resident briefly. During the visit one resident was already at their day program and the other was conducting a medical call when LPA arrived and soon after left for day program.

At 1:10 pm LPA Rankin traveled to Options main office to review staffing records.

Staffing and Training Records: Staff records are kept confidential. LPA reviewed 5 staff files for 1st AID, Fingerprint clearances, Applications, Health exam with TB results, and Criminal Record statements. All required personnel and training documents were present.

Exit interview conducted and copy of report read and printed for Fran Walker, Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024

LIC809 (FAS) - (06/04)

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