405802277-4-26-2023-29-AS-DCHZ-CRA2SC-20230426173854

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802277
Report Date: 04/26/2023
Date Signed: 04/26/2023 05:40:00 PM

Document Has Been Signed on 04/26/2023 05:40 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 V		FACILITY NUMBER:	405802277
ADMINISTRATOR:	CORRALES, NELLIE		FACILITY TYPE:	740
ADDRESS:	3210 FLORA STREET		TELEPHONE:	(805) 439-2504
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	6	CENSUS: 6	DATE:	04/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Joel Wobrock, Licensee, and Deborah Cole, Back-up Administrator		TIME COMPLETED:	06:05 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) Chavez made an unannounced 1-year required annual visit to the facility above. LPA met with Joel Wobrock, Licensee/Administrator, and Deborah Cole, Back-up Administrator, and explained the purpose of the visit. LPA requested a staff roster, a resident roster, emergency and disaster plan, and documentation of quarterly emergency drills. LPA toured the facility with back-up administrator and the following was noted: LPA observed the license posted, licensing reports, personal rights, non-discrimination notice, LTCO poster, CDSS Complaint Poster, Bill of Rights and Right to Residential Council. The facility has 5 bedrooms and 4 bathrooms, a kitchen, dining room/living room, courtyard in the back of the facility, and garage. Medications are kept in a locked cabinet in the garage. Physical plant was check for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, and all were in good condition. The facility maintains a comfortable temperature. The facility provides a working telephone for resident use. Dual smoke and carbon monoxide detectors are hard wired and were tested and operational. Fire extinguishers located in the garage and hall near garage were last inspected 04/07/23 and 4/26/23 and are charged in the green. There are no issues with Fire Clearance. Living and dining room furniture were also checked for functionality and condition. The living room is clean, safe and sanitary along with the dining room. Courtyard of the facility has outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. There is plenty of outdoor lighting available for the safety of the residents. External gates (3) had latches/locks on the exterior, making it difficult for residents to open. Technical violation given. Kitchen was sufficiently stocked with two-day perishable and seven-day non-perishables. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. Continued on 809-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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 04/26/2023 05:40 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: BOB & CORKY'S CARE HOME V	FACILITY NUMBER: 405802277
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews, the licensee did not comply with the section cited above in one out of five residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2023
	Plan of Correction
1 2 3 4	Licensee will ensure R1 has a TB test with negative results, and will send CCL a copy by 5/3/23.

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	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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: BOB & CORKY'S CARE HOME V	FACILITY NUMBER: 405802277
	VISIT DATE: 04/26/2023

NARRATIVE

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Resident rooms have beds with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and enough lighting for each resident. There is enough linen available to change weekly or more, if need.
Bathrooms were checked for cleanliness and proper operation. The hot water temperature measured between 114 F and 116 F degrees in resident bathrooms. Towels and washcloths are not shared. Residents have a sufficient amount of supplies for personal hygiene. Soap, paper towels and toilet paper are provided by the Licensee. Grab bars are secured in toilet and shower areas. Showers have non-slip bottoms or mats.
Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for current Medical Assessments with TB results, Current Appraisal Needs and Service plans, and signed Admission Agreements. There was no documentation showing TB results for Resident #1 (R1). Licensee states and the physician report shows a chest x-ray was completed, but the results are not listed. Deficiency cited. Planned activities are offered to residents in care.
Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations, Health screening with TB results, current First Aid/CPR, and Administrator Certificate. The CPR/first-aid certificate for Staff #1 (S1) expired on 3/23/23. Technical violation given. LPA reviewed Staff Training Records. Training records were present with a minimum of 20 hours completed for the past year.
Medications are in a centrally stored and locked cabinet in the garage, including over-the-counter medicines. Medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the residents’ doctor. Proper medication dispensing instructions are followed. The first aid kit has all proper items and is current.

Exit interview conducted, deficiency cited and the report and appeal rights given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC809 (FAS) - (06/04)

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