405801740-4-13-2023-29-AS-DCHZ-CQV2Q3-20230413173516

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801740
Report Date: 04/13/2023
Date Signed: 04/13/2023 05:36:45 PM

Document Has Been Signed on 04/13/2023 05:36 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:	BOB & CORKY'S CARE HOME		FACILITY NUMBER:	405801740
ADMINISTRATOR:	JOEL WOBROCK		FACILITY TYPE:	740
ADDRESS:	2425 GERDA STREET		TELEPHONE:	(805) 400-0506
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	6	CENSUS: 5	DATE:	04/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Joel Wobrock, Licensee/Administrator		TIME COMPLETED:	06:00 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) Chavez made an unannounced 1-year required annual visit to the facility above. LPA met with Joel Wobrock, Licensee/Administrator, and Deborah Cole, Administrator, and explained the purpose of the visit. LPA requested a staff roster, a resident roster, emergency and disaster plan, and documentation of quarterly emergency drills. LPA requested documents and asked for a physical plant tour. A tour of the physical plant was assessed, and the following was noted: LPA observed the license posted, licensing reports, personal rights, non-discrimination notice, LTCO poster, CDSS Complaint Poster, Bill of Rights and Right to Residential Council. The facility has 4 bedrooms and 3 bathrooms, a kitchen, dining room, living room, courtyard in the back of the facility, and garage. Medications are kept in a locked cabinet in the kitchen. Physical plant was check for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, and all were in good condition. The facility maintains a comfortable temperature. The facility provides working telephones for resident use. Dual smoke and carbon monoxide detectors are hard wired, tested, and operational. A fire extinguisher located in the kitchen was last inspected 04/07/23 and is charged in the green. There are no issues with Fire Clearance. Living and dining room furniture were also checked for functionality and condition. The living room is clean, safe and sanitary along with the dining room. Continued on 809-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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 3

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: BOB & CORKY'S CARE HOME	FACILITY NUMBER: 405801740
	VISIT DATE: 04/13/2023

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

Courtyard of the facility has outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. There is plenty of outdoor lighting available for the safety of the residents.
Kitchen was sufficiently stocked with two-day perishable and seven-day non-perishables. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. The garbage can is in the cabinet under the kitchen sink.
Resident rooms have beds with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and enough lighting for each resident. There is enough linen available to change weekly or more if need.
Bathrooms were checked for cleanliness and proper operation. The hot water temperature measured between 106 F and 110 F in resident bathrooms #1 – 3. Towels and washcloths are not shared. Residents have a sufficient amount of supplies for personal hygiene. Soap, paper towels and toilet paper are provided by the Licensee. Grab bars are secured in toilet and shower areas. Showers have non-slip bottoms.
Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for current Medical Assessments with TB results, Current Appraisal Needs and Service plans, and signed Admission Agreements. Planned activities are offered to residents in care.
Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations, Health screening with TB results, current First Aid/CPR, and Administrator Certificate which expired on 11/21/22. The administrator states he mailed to CDSS the required documentation two weeks prior to certificate lapsing and has not received the updated certificate yet. LPA viewed the CDSS site, the administrator’s certification is listed as pending. LPA reviewed Staff Training Records. Training records were present with a total of 14-19 hours completed and missing 1-6 hours annually. Additionally, required training did not include the minimum 4 hours of postural supports, restricted health conditions, and hospice training and minimum 8 hours of general training, thereby not meeting the minimum total 20 hours of annual training for five staff records reviewed. Deficiency cited.
Medications are in a centrally stored and locked cabinet in the kitchen, including over-the-counter medicines. Medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the residents’ doctor. Proper medication dispensing instruction are followed. The first aid kit has all proper items and is current.

Exit interview conducted, deficiency cited and the report and appeal rights given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 04/13/2023 05:36 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: BOB & CORKY'S CARE HOME	FACILITY NUMBER: 405801740
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

(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 review and interviews, the licensee did not comply with the section cited above in 15 out of 5 training records which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/20/2023
	Plan of Correction
1 2 3 4	Licensee will conduct training hours needed for staff to meet the minimum 20 hours annual training requirements. Licensee will send CCL the training certificates by end of day 4/20/23.

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	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3