405801706-3-30-2023-29-AS-RDLN-CQF292-20230330171114

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801706
Report Date: 03/30/2023
Date Signed: 03/30/2023 05:15:18 PM

Document Has Been Signed on 03/30/2023 05:15 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:	WELCOME HOME II (RCFE)		FACILITY NUMBER:	405801706
ADMINISTRATOR:	EVELYN I. FLORENTINO		FACILITY TYPE:	740
ADDRESS:	1555 16TH STREET		TELEPHONE:	(805) 439-1490
CITY:	LOS OSOS	STATE: CA	ZIP CODE:	93402
CAPACITY:	6	CENSUS: 4	DATE:	03/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Edwin Ingan, Back up to Administrator		TIME COMPLETED:	05:20 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 10:30 am to conducted a 1 year annual visit to the facility above. LPA met with staff that called Back-up Administrator Edwin Ingan to come to the facility. LPA met with Edwin Ingan at 11:30 am and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Back up Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Mitigation Plan, Infection Control Plan and an up to date Emergency Disaster Plan to the department. The facility has signs in the common areas regarding Covid-19. 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. Sick staff are requested to stay home and not report to work if ill. Physical Plant & Environment Safety: The facility is a 3 bedroom and 2 bathroom home currently occupying 4 residents and 6 staff. The water was tested in resident bathroom #1 and measured at ____. The facility is clean, safe and sanitary. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The gates are self closing, one gate is self latching and one gate needs repair to be self latching. The kitchen screen door needs to be repaired put back on track to open and close properly.The facility has table and chairs available outside with shaded area for resident use. Laundry room has working washer and dryer.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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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Document Has Been Signed on 03/30/2023 05:15 PM - It Cannot Be Edited

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: WELCOME HOME II (RCFE)	FACILITY NUMBER: 405801706
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record reviwew the licensee did not comply with the section cited above in 6 of 6 staff did not have current annual 2023 trianing which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/07/2023
	Plan of Correction
1 2 3 4	Administrator agreed to get all 6 staff training up to date and submit records to CCL.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in The facility was not comducting quarterly drills for emergencies which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/07/2023
	Plan of Correction
1 2 3 4	Administrator agreed to hold quarterly emegnecy drills and provide CCL with a copy of the first drill conducted for all staff.

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: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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: WELCOME HOME II (RCFE)	FACILITY NUMBER: 405801706
	VISIT DATE: 03/30/2023

NARRATIVE

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Operational Requirements: The Facility is operating in compliance with fire clearance. The facility provided current up to date liability insurance. All Dementia requirements are being met. Hospice wavier granted for 3 and 1 resident is currently on hospice services.

Staffing: The facility employes 6 staff and staff records are kept confidential. Staff records were reviewed for 6 staff. Staff records had finger print clearance and associations with criminal record statements, personnel record or application, First Aid and CPR certificates and Health screening with TB results.

Personnel Records & Training: The facility keeps confidential files for each staff member. Training records were not current for required 2023 annual training requirements.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four Files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), Immunization records, TB results, Personal Rights, and Safeguard for personal property and valuables. 3 out of 4 residents needed updated ANS and LIC 602A physician report. Facility does submit incident reports to the department when required.

Resident Rights Information: All require posting for residents were posted in common areas of facility. Personal rights, Rights to Resident Council, Theft and Loss policy, CCL Complaint poster, and LTCO poster. Nondiscrimination notice is signed in admission agreements but not posted in the facility as required.

Planned Activities: The facility offers activities to all residents in care. Activities include books, magazines ,newspapers, TV watching, daily walks, group discussions and communications, arts and crafts. 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: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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: WELCOME HOME II (RCFE)	FACILITY NUMBER: 405801706
	VISIT DATE: 03/30/2023

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. Food, snacks and drinks are available when the residents want them.

Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed for all 4 residents in care both Medication Administration Records (MAR) and Centrally Stored Medication and Destruct Records (CSMDR) were current and up to date. 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. Doctors orders were reviewed for bed rails ordered by the physicians.

Disaster Preparedness: The current emergency disaster forms were posted and up to date. The facility could not provide quarterly disaster drills. The fire extinguishers were charged and last inspected on 11/07/2022. The dual smoke and carbon detectors are present and hard wired throughout the facility. The facility has a sprinkler system.

Residents with Special Health Needs: The facility has dementia residents in care. All items that could pose a danger, sharps, cleaners were locked separately in cupboards. The facility has a license for 1 bedridden on room 2, currently no bedridden resident in care. The facility does not have any delayed egress. The facility does not have any current residents with oxygen but does have signs to display when and if needed.

LPA conducted interviews with 1 Resident and 3 Staff.

Exit interview conducted, Deficiency cited, Technical violations issued, Copy of report and appeal rights provided to Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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