405801832-7-29-2023-29-AS-RDLN-CU83BQ-20230729180644

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801832
Report Date: 07/29/2023
Date Signed: 07/29/2023 06:44:55 PM

Document Has Been Signed on 07/29/2023 06:44 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:	WILCOX'S MESA HOME		FACILITY NUMBER:	405801832
ADMINISTRATOR:	BRANDEE CHURCH		FACILITY TYPE:	735
ADDRESS:	711 RIDGE ROAD		TELEPHONE:	(805) 929-3118
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY: 4		CENSUS: 4	DATE:	07/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Brandee Church, Administrator		TIME COMPLETED:	06:15 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 11:00 am to conducted a 1 year annual visit to the facility above. LPA met Administrator Brandee Church 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 Mitigation Plan, Infection Control Plan and provide plans 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 & Environment Safety: The facility has 4 client bedrooms and 1 Client bathroom currently occupying 4 clients and employs 6 staff. The Licensee lives in the facility and has 1 bedroom and 1 bathroom dedicated for use. The staff have a staff room and bathroom. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for clients comfort. The facility kitchen is clean, safe and sanitary. The shower have non-skid mat. 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 closet off living room. The facility has sufficient space inside and outside for activities and visiting. The facility has a large yard and decks for client use with plenty of shade. The facility has telephone and internet service for client use. Water temperature was within regulation requirements and facility checks temperature often.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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 07/29/2023 06:44 PM - It Cannot Be Edited

Created By: Rachael De Leon On 07/29/2023 at 04:24 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: WILCOX'S MESA HOME	FACILITY NUMBER: 405801832
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. 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 1 out 6 out of statf had an expired 1st AID which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/29/2023
	Plan of Correction
1 2 3 4	Administrator renewed 1st AID/CPR while LPA was at the facility on 07/29/2023

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:

Rachael De Leon

LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2023

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: WILCOX'S MESA HOME	FACILITY NUMBER: 405801832
	VISIT DATE: 07/29/2023

NARRATIVE

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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 Non-Ambulatory.

Staffing: The facility employes 5 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 staff files. Files reviewed had 1 out of 6 staff without 1st Aid/CPR but was completed and showed to LPA before leaving visit, 1 out of 6 files did not have the Personnel Records/Application on file, 5 out of 6 staff were missing the original Health screening, 4 out of 6 staff were missing original TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions were on file. Administrator Certificate was expired and administrator is currently working on completing CEU for renewal application. Administrator is working on reproducing records that had been damaged and no longer legible.

Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 6 staff training records. 3 out of 6 had required training completed for 08/2022 and 09/2022, 1 staff had completed CPI Training expires in 08/27/2023, ALL Staff have DSP Training scheduled for 08/2023 for 40 hours.

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

Clients Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four files were reviewed for signed Admission Agreements 3 out of 4 clients were missing admission agreement, Medical Assessments LIC. 602A Physicians Report 1 out of 4 clients were missing from file, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS) are done as IPP and ISP and completed quarterly and annually 2 out of 4 clients were missing the most current annual IPP, 1 out 4 clients were missing TB results, Personal Rights, and 3 out of 4 clients were missing Safeguard for personal property and valuables. The Facility does handle cash resources for 2 clients in care. LPA audited 2 clients funds with ledgers, cash, and receipts. The facility Surety bond is current. Facility does submit incident reports to the department when required. The facility has a current application for change in location due to the property is being put up for sale as soon as CCL approves the new location application. The Administrator is working with TCRC to replace some of the damaged forms from client files.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2023

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: WILCOX'S MESA HOME	FACILITY NUMBER: 405801832
	VISIT DATE: 07/29/2023

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. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the clients want them. Emergency supply of food and water is available. Modified diets prescribed by a physician are followed for those clients in care. 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. First Aid is provided to clients in care. Clients medication records for prescriptions had doctors orders present. The facility uses the Medication Administration Records (MAR) and Centrally Stored Medication and Destruct Record (CSMDR) for client medications.

Incidental Medical Services: Facility provides transportation to medical and dental appointments when needed. The facility had a 1st Aid Kit present.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged. 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.

LPA conducted interviews with 2 Staff and 2 Clients.

Exit interview conducted, deficiency issued, copy of report and appeal rights printed for Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2023

LIC809 (FAS) - (06/04)

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