<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801832
Report Date: 07/17/2024
Date Signed: 07/17/2024 03:43:35 PM

Document Has Been Signed on 07/17/2024 03:43 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 HOMEFACILITY NUMBER:
405801832
ADMINISTRATOR/
DIRECTOR:		SHANNON MACKENZIEFACILITY TYPE:
735
ADDRESS:711 RIDGE ROADTELEPHONE:
(805) 929-3118
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 4CENSUS: 4DATE:
07/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Teresa Becerra, Back up to AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:48 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 Back-up Administrator Teresa Becerra 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. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, and hand soap. 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, employs 6 staff and 1 Administrator. The Licensee lives in the facility and has 1 bedroom and 1 bathroom dedicated for use. The staff have a staff room and bathroom upstairs on 2nd floor and it is not currently being occupied by any staff. 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. Continued 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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 11
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: 07/17/2024
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
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 FOUR (4) NON-AMBULATORY OF WHICH TWO (2) MAY BE BEDRIDDEN IN BEDROOMS 1,2,3,OR 4. HOSPICE WAIVER FOR TWO (2). AGE RANGE 18-59 YEARS OLD.

Staffing: The facility employes 6 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 staff files. Files reviewed had 1st Aid/CPR, Personnel Records/Application on file, 4 out of 5 staff were missing the original Health screening with original TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions were on file. Administrator Certificate was expired and LPA verified Administrator is currently on the pending list for renewal.

Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 6 staff training records and all staff had current DSP 1 and working on DSP 2. Administrator had both DSP 1 & 2 completed. LPA verified with Tri-Counties Regional Center (TCRC) Quality Assurance (QA) that CPI was not required.

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. 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 1/4 was missing Administrator getting copy from TCRC. Medical Assessments LIC. 602A Physicians Reports, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and 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. 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: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
LIC809 (FAS) - (06/04)
Page: 10 of 11
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: 07/17/2024
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. 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. 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. LPA audited 4 residents medication no expired medication, prescription labels were not altered and medications were stored in original containers.

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 1 Staff and 2 Clients.

Exit interview conducted and copy of report printed for Back up to Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
LIC809 (FAS) - (06/04)
Page: 11 of 11