405801992-12-22-2023-29-AS-RDLN-CYRW3C-20231222155542

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801992
Report Date: 12/22/2023
Date Signed: 12/22/2023 03:55:48 PM

Document Has Been Signed on 12/22/2023 03:55 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:	CASA DE LUNA		FACILITY NUMBER:	405801992
ADMINISTRATOR:	FRANCYN ALTAMIRA		FACILITY TYPE:	735
ADDRESS:	8805 CARMELITA AVENUE		TELEPHONE:	(805) 460-7090
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY: 4		CENSUS: 2	DATE:	12/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Steve Rodriguez, Licensee and Francyn Altamira Administrator		TIME COMPLETED:	04:05 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 10:20am to conducted a 1 year annual visit to the facility above. LPA met with Licensee Steve Rodriguez and Administrator Francyn Altamira. LPA explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Infection Control Plan 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 & Environmental Safety: The facility is a 4 bedroom and 2 bathroom currently occupying 2 residents and employs 3 staff, 1 live-in Licensee, and 1 Administrator. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. Carbon Monoxide was tested and working on visit. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational. The water was tested in residents restroom at 114.8 F. Water temperatures were within regulation requirements. 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 in care locked in laundry room cupboards and under the kitchen sink. The facility has sufficient space inside and outside for activities and visiting. The facility has telephone and internet service for resident use. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

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: CASA DE LUNA	FACILITY NUMBER: 405801992
	VISIT DATE: 12/22/2023

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

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 is approved for a capacity of 4 Ambulatory.

Staffing: The facility employes 5 staff. Staff records are kept confidential. LPA reviewed 5 staff files for 1st AID/CPR, Finger print clearances, Applications, Health exam with TB results, and Criminal Record statement.

Personnel Records & Training: The facility keeps confidential files for each staff member. 5 staff had current 1st AID/CPR/AED, Records were present and up to date. Initial and Annual Training requirements are being met for 2023.

Clients Rights: All require postings were posted in the common area of the facility. Personal rights and Complaint poster is posted. The current license along with CCL reports and PIN's were posted. Visitation policy is posted at entry. Internet is provided to each resident and each resident is given confidentiality and privacy.

Clients Records & Incident Reports: The facility keeps separate files on each resident confidentially. Two files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), IPP, TB results, Personal Rights, and Safeguard for personal property and valuables. The Facility does handle cash resources for residents in care. LPA audited 2 residents funds with ledgers, cash, and receipts, and were all balancing. The facility Surety bond is current. 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: 12/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

LIC809 (FAS) - (06/04)

Page: 2 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: CASA DE LUNA	FACILITY NUMBER: 405801992
	VISIT DATE: 12/22/2023

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

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 45 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. 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. Transportation is arranged or provided for medical and dental appointments. The facility does not have any resident with prohibited or restricted health condition.

Incidental Medical Services: Clients medication records were reviewed, prescriptions had doctors orders, and PRN medications were checked for expiration date, no labels were altered and medication is stored in original packages. The facility uses the Medication Administration Record (MAR) and the Centrally Stored Medication and Destruct Record (CSMDR).

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 04/12/2023. 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.

Emergency Intervention: This facility does not take this training as it is not required through TCRC.

LPA conducted interviews with 2 Staff and 2 residents.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3