405801714-9-16-2024-29-AS-MRAN-D96THL-20240916144454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801714
Report Date: 09/16/2024
Date Signed: 09/16/2024 02:45:03 PM

Document Has Been Signed on 09/16/2024 02:45 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:	BAUER RESIDENTIAL-NIPOMO		FACILITY NUMBER:	405801714
ADMINISTRATOR/ DIRECTOR:	SHIRLET HALLIDAY		FACILITY TYPE:	735
ADDRESS:	890 PROSPERITY WAY		TELEPHONE:	(805) 929-5758
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY: 4		CENSUS: 4	DATE:	09/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	SHIRLET HALLIDAY		TIME VISIT/ INSPECTION COMPLETED:	03:00 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) Rankin arrived at 10:00 am to conduct 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: Physical Plant & Environmental Safety: The facility is 4 bedroom and 2 1/2 bathroom facility currently occupying 4 residents and employs 9 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 and smoke alarms were tested and working properly on the visit. 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. 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 and hall cabinet. The facility has sufficient space inside and outside for activities and visiting. There shaded areas in front and back for client use. The facility has telephone and internet service for resident use. Operational Requirements: The facility is operating in compliance with the granted fire clearance in regard to client usage. The facility is approved for a capacity of 4 with 1 Ambulatory and 3 Non-Ambulatory. The facility is equipped with exiting door alarms. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

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 5

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: BAUER RESIDENTIAL-NIPOMO	FACILITY NUMBER: 405801714
	VISIT DATE: 09/16/2024

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

Staffing: The facility employes 8 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 personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Administrator certificate expires 2/22/2026.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff files had 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 had incident reports available for review. Reports had been submitted to tri-counties, new process will ensure they are submitted to CCL.

Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: BAUER RESIDENTIAL-NIPOMO	FACILITY NUMBER: 405801714
	VISIT DATE: 09/16/2024

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. 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 cabinet. 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 multiple first aid kits.

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. A sampling of medications were reviewed, and checked for expiration dates, 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 07/23/2024. 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.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

Page: 5 of 5