405801960-11-15-2024-29-AS-RDLN-DB2TFA-20241115134113

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801960
Report Date: 11/15/2024
Date Signed: 11/15/2024 01:41:35 PM

Document Has Been Signed on 11/15/2024 01:41 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 III		FACILITY NUMBER:	405801960
ADMINISTRATOR/ DIRECTOR:	DEBORAH COLE		FACILITY TYPE:	740
ADDRESS:	2456 SANTA CLARA		TELEPHONE:	(805) 400-0506
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:35 AM
MET WITH:	Deborah Cole, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:50 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 10:35 am to conducted a 1 year annual visit to the facility above. LPA met with Administrator Debra Cole 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 a current Infection Control Plan. 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 when and if needed. 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 has 5 resident bedrooms and 3 resident bathroom currently occupying 6 residents and employs 10 staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. 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 residents are locked under the kitchen sink and in the locked garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard and side yards for client use with an umbrella for shade. Telephone and internet service is provided for resident use. The facility has a working washer and dryer. Continued 809-C

Kelly Burley	TELEPHONE: (805) 562-0413
Rachael De Leon	TELEPHONE: (805) 450-0262
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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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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 III	FACILITY NUMBER: 405801960
	VISIT DATE: 11/15/2024

NARRATIVE

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Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 04/19/2024. The facility is approved for a capacity of 6 with 4 NON-AMBULATORY, 1 BEDRIDDEN (ROOM #5), 1 AMBULATORY and HOSPICE WAIVER FOR 3.

Staffing: The facility employes 10 staff and 2 administrators. Staff records are kept confidential. LPA reviewed 5 staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate expires 11/21/2024, other Administrator is expired and showing on the pending list, all renewal paperwork in in file.

Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for Initial training of 40 or Annual training of 20 plus hours meeting 8 hours of dementia training with all subjects covered over a 3 year period, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness, policy, procedures, infection control, and PPE requirements. Quarterly Disaster Drills are completed. Staff handling medications had annual medication training of 8 hours. Trainers met the requirements to train staff with required information present in files. Hospice and Home Health have training records on file.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five 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 personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The facility does not handle cash resources for any of the residents in care. Facility does submit incident reports to the department when required.

Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license is posted. Visitation policy is posted at entry. Internet is provided to residents in care with confidentiality and privacy. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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: BOB & CORKY'S CARE HOME III	FACILITY NUMBER: 405801960
	VISIT DATE: 11/15/2024

NARRATIVE

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Food Service: The facility kitchen is clean, safe and sanitary. 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 residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff were observed for personal hygiene and food sanitation practices.

Incidental Medical Services: Facility provides or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). Medications for all resident in care are centrally stored. LPA reviewed medications and records. No medications label were altered and medications were checked for expiration dates. Medication were given as prescribed with physicians orders. The Administrator and the medication technician do the medication destruct at facility together.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. 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. Facility has emergency food and water supply, flash lights with batteries, and a cooler with ice packs or dry ice for medications. The facility has two evacuation locations and a generator in place if needed.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. Oxygen signs are posted. The facility currently has residents receiving hospice services and home health services. Hospice and Home Health care plans are kept on file and up to date. The facility does not have any delayed egress. The facility has one self latching and self closing gate. All exiting doors are alarmed. There are no bodies of water on the premises.

LPA conducted interviews with 2 staff and 2 residents.

Exit interview conducted and copy of report printed for Administrator

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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