405801561-8-31-2022-29-AS-DCHZ-CHU27N-20220831170900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801561
Report Date: 08/31/2022
Date Signed: 08/31/2022 05:09:47 PM

Document Has Been Signed on 08/31/2022 05:09 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:	TRAFFIC WAY HOUSE		FACILITY NUMBER:	405801561
ADMINISTRATOR:	DEBBIE STARLING		FACILITY TYPE:	735
ADDRESS:	5000 TRAFFIC WAY		TELEPHONE:	(805) 466-0721
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY: 14		CENSUS: 6	DATE:	08/31/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Debbie Starling, Administrator		TIME COMPLETED:	05:25 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	On 8/31/22 at 3:00 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility listed above. LPA met with Debbie Starling, Administrator, and explained the purpose of the visit. Administrator stated that all clients were away at camp, with the exception of one client who remained in the facility. LPA toured the facility with the administrator and observed the following: The facility has soap and paper towels in resident bathrooms. The fire extinguishers (4) are located across from the office, one in each hallway leading to resident bedrooms, and one in the kitchen. The extinguishers are fully charged and were inspected on 10/21/21. The facility does not have infection control signage at the front door nor signage throughout the facility on handwashing, cough etiquette and use of masks. Administrator will post infection control signage on or near the front door, in common areas, and in bathrooms, then take photos and send to LPA by 9/1/22. Upon entry to the facility, LPA was screened. Staff were not wearing masks. LPA instructed administrator who was in the common area to put a mask on and explained that since there is at least one client in the home, staff must wear masks. Administrator immediately placed a mask on. However, the facility did not protect the personal rights of clients in care to be able to receive safe and healthful accommodations in that the facility staff failed to wear face coverings properly while providing care and supervision to residents in care. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions. Pursuant to Title 22, California Code of Regulations, the deficiency will be cited on 809-D. At 3:45 pm LPA conducted the Infection Control mitigation module with the administrator. Exit interview conducted, deficiency cited and the report and appeal rights emailed to the administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

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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Document Has Been Signed on 08/31/2022 05:09 PM - It Cannot Be Edited

Created By: Darlene Chavez On 08/31/2022 at 04:43 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TRAFFIC WAY HOUSE	FACILITY NUMBER: 405801561
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80072(a)(2)

80072(a)(2) Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Administrator was not wearing a mask upon LPA’s entrance to the facility.
	POC Due Date: 09/01/2022
	Plan of Correction
1 2 3 4	Administrator will review the regulation cited, write a Statement of Understanding, and commit to training all staff on mask requirements. Administrator will send the Statement to LPA by end of day 9/1/22 along with a commitment to train staff by 9/6/22 on mask wearing policies.

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

LICENSING EVALUATOR NAME:

Darlene Chavez

LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC809 (FAS) - (06/04)

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