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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801985
Report Date: 07/12/2024
Date Signed: 07/12/2024 01:53:13 PM


Document Has Been Signed on 07/12/2024 01:53 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:PASO SENIOR CAREFACILITY NUMBER:
405801985
ADMINISTRATOR:MEYNARD MARCOSFACILITY TYPE:
740
ADDRESS:197 CARDINAL WAYTELEPHONE:
(805) 835-4762
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 6DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maynard Marcos (phone) AdministratorTIME COMPLETED:
02:01 PM
NARRATIVE
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 At 9:30am on 07/12//2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with care giver Mylene Cavello (S1), who called administrator Maynard Marco by phone who provided permission for S1 to sign for inspection visit. LPA noted that S1 has a LIC308, Designation of Facility Responsibility for this facility on file with CCLD.
S1 and LPA conducted a physical tour of the facility. LPA noted that all exits were free and clear of hazards. LPA noted that all rooms have a working combination carbon monoxide/smoke detector unit that are all hardwired and currently working. LPA noted that all rooms are properly finished with correct bedding linin, personal storage and lighting in accordance with regulations. LPA noted that there is ample linin and personal hygiene and incontinence supplies for all 5 residents presently at the facility. This facility has 5 resident bedrooms, 4 are single occupancy and 1 in double occupancy. The facility has 3 bathrooms all meeting regulations standards. Water in the facility was tested at bathroom 1 and bathroom 3 and found to be within the regulation temperature range of 105*-120* (f). LPA observed there to be more than 2 days of perishable foods and more than 7 days of non-perishable foods for the 6 residents and staff. LPA observe the outside grounds of the facility and noted that patio tables have table umbrellas for shade when residents are utilizing outdoor area of facility. LPA noted that the facility to be clean and in good repair with no hazards present on facility physical tour. LPA found no technical, violations or citations during the physical tour at this time.
S1 and LPA conducted a full review of the control tools modules. It was discovered that annual staff training was not completed per regulations for the past 12 month period and a citation was issued for staff annual training (Health and Safety Code 1569.625(b)(2)); It was also discovered that there had been no emergency drills conducted over the past 12 months and no documentation of drills (Health and Safety Code 1569.695(c)). LPA issued two citations, with plan of corrections for two violations. LPA concluded the annual facility inspection.
Exit interview, report read, citations issued, appeal rights and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
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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Document Has Been Signed on 07/12/2024 01:53 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: PASO SENIOR CARE
FACILITY NUMBER: 405801985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(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
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Based on record review of 4 of 4 staff records, the licensee did not comply with the section cited above in 4 out of 4 staff training records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Licensee agrees to immediately being scheduling all staff for annual training to be meet regulation requirements within 60 days. Licensee will email LPA on progress. (mark.jeffries@dss,ca,gov)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 of 4 quarterly drills, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Licensee agrees to conduct an emergency drill of choice for all shifts in the next two weeks and document per regulations requirements. Licences will provide proof of emergency drills and documentation to LPA by email before 07/26/2024. (mark.jeffries@dss.ca.gov)
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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
LIC809 (FAS) - (06/04)
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