405801714-9-13-2023-29-AS-RDLN-CVN24N-20230913170413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801714
Report Date: 09/13/2023
Date Signed: 09/13/2023 05:04:33 PM

Document Has Been Signed on 09/13/2023 05:04 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:	BAUER RESIDENTIAL-NIPOMO		FACILITY NUMBER:	405801714
ADMINISTRATOR:	RANDEEN P DOMINGUEZ		FACILITY TYPE:	735
ADDRESS:	890 PROSPERITY WAY		TELEPHONE:	(805) 929-5758
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY: 4		CENSUS: 4	DATE:	09/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Shirlet Halliday, Administrator		TIME COMPLETED:	05:10 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 10:45 am to conducted a 1 year annual visit to the facility above. LPA met with Administrator Shirlet Halliday 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 Infection Control Plan to the department. The facility has a sign in and out binder for visitors at entry with hand sanitizer. 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 a 30 day supply of PPE. 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 & Environmental Safety: The facility is a 4 bedroom and 2 1/2 bathroom currently occupying 4 residents and employs 6 staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. Carbon Monoxide was tested and working properly on the visit. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to clients in care locked in garage. The facility has sufficient space inside and outside for activities and visiting and an umbrella for shade. The facility has telephone and internet service for resident use. Water temperature is within regulation requirements of 105-120 degrees F. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 9

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: BAUER RESIDENTIAL-NIPOMO	FACILITY NUMBER: 405801714
	VISIT DATE: 09/13/2023

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
26
27
28
29
30
31
32

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 is approved for a capacity of 4 with 1 Ambulatory and 3 Non-Ambulatory. The facility is equipped with exiting door alarms. The facility has side gates that are self-latching and self closing.

Staffing: The facility employes 5 staff and 1 Administrator. Staff records are kept confidential and locked in staff office. LPA reviewed 4 random staff files and 1 Administrator file. Files reviewed had current 1st Aid/CPR for 4 staff and 1 Administrator, 1 staff expired on 09/04/2023 and is renewing it on LPA visit staff provided updated 1St Aid/CPR renewal before LPA left visit, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for meeting the Continuing Education requirements, HIV/TB training has not been completed and Administrator has 3 more months to complete. LPA verified Administrator on the ARF Certification list as pending.

Personnel Records & Training: The facility keeps confidential files for each staff member. 2/5 Staff files had annual training. 2 staff are currently completing annual training. All staff had current CPI training certifications.

Clients Rights: All require postings were posted in the common area of the facility. Personal rights of Persons with disabilities and ARF Personal Rights, CCL Complaint poster is posted at entry. The current license along with CCL reports and PIN's were in the staff office. Visitation policy is posted at entry. Internet is provided to each resident and each resident is given confidentiality and privacy.

Clients Records & Incident Reports: The facility keeps separate files on each client confidential locked in staff office. 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), TB results, Personal Rights and Safeguard for property and valuables. The Facility does handle cash resources for all clients in care. Facility Surety Bond is current. LPA audited all four residents cash resources, ledger, receipts and balances were all present and correct. Facility does submit incident reports to the department when required.

Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

LIC809 (FAS) - (06/04)

Page: 2 of 9

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: BAUER RESIDENTIAL-NIPOMO	FACILITY NUMBER: 405801714
	VISIT DATE: 09/13/2023

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
26
27
28
29
30
31
32

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. The freezer is kept at 0 degrees and the refrigeration is kept at 45 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. Residents in care are not currently on a modified diets prescribed by a physician. 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.

Health Related Services: Facility provides Centrally Stored Medications to all clients in care. Medications are kept in a locked medication cabinets. Facility does not have any clients with prohibited or restricted health conditions. Doctor orders and prescriptions are present in client files, First Aid is provided to clients in care with privacy. Facility has a first aid kit.

Incidental Medical Services: Facility provides transportation or arranges transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) and the Centrally Stored Medication and Destruct Record (CSMDR) for all residents in care. All medications were reviewed, checked for expiration dates which 1 residents had an expired PRN as 09/02/2023 and last use was 08/17/2023 Administrator will destroy medication properly and called pharmacy for a refill, none of the medication labels were altered. The Administrator and additional staff complete destruct records and take medications to Hometown Pharmacy for destruction.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 07/24/2023. 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. Administrator is currently updating plan and will provide CCL with a current update.

Emergency Intervention: All 6 staff have current CPI Non-Violent Crisis Intervention Training Certificates. The facility is a hands off facility and does not use manual restraint or seclusion.

LPA conducted interviews with 2 staff and 2 residents.
Exit interview conducted and copy of report printed for Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

LIC809 (FAS) - (06/04)

Page: 3 of 9