405802295-4-7-2023-29-AS-DCHZ-CQP2UG-20230407174221

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802295
Report Date: 04/07/2023
Date Signed: 04/07/2023 05:49:49 PM

Document Has Been Signed on 04/07/2023 05:49 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:	RESIDENCE IV, THE		FACILITY NUMBER:	405802295
ADMINISTRATOR:	MARCOS, MEYNARD		FACILITY TYPE:	740
ADDRESS:	347 CALLE LUPITA		TELEPHONE:	(805) 549-0328
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	6	CENSUS: 6	DATE:	04/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Meynard Marcos, Licensee/Administrator		TIME COMPLETED:	06:00 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 Analysts (LPAs) Chavez and De Leon arrived at the facility at 9:22 am and made an unannounced 1-year required annual visit to the facility above. LPAs met with Meynard Marcos, Licensee/Administrator, and explained the purpose of the visit. LPAs requested a staff roster, a resident roster, emergency disaster plan, documentation of quarterly emergency drills. LPAs provided administrator the entrance checklist and asked for a physical plant tour. A tour of the physical plant was assessed, and the following was noted: LPAs observed the license posted, personal rights, LTCO poster, CCL Complaint poster and COVID signs. The facility has 6 bedrooms with 3 bathrooms, kitchen, living room, dining room, garage, and medications locked in a cabinet in the kitchen, covered patio with chairs for resident use outside. Physical plant was checked for cleanliness and condition. Walls and baseboards had markings, the wall in the dining room has a puncture with broken stucco and paint coming off, windows and sliding glass doors have dirt/dust, the ceiling in the entrance way has pieces breaking off and per the licensee, it was leaking water during recent storms, walls in dining area have unfinished painting, and dust on appliances. The sliding door in the dining room was missing an exiting door alarm. The garage storage room has a bent window screen with small holes/breaks in it. The facility needs to fix outside gates to be self-closing and self-latching. The kitchen vent and cabinets above have grease and need cleaning, the microwave has food splattered on the walls, and the kitchen floor is sticky. The facility maintains a comfortable temperature. The facility provides working telephones and on-line communication for resident use. The smoke detectors are hard wired, tested and working properly. The carbon monoxide detector was tested and operational. A fire extinguisher was last inspected 6/5/22 and shows charged in the green. There are no issues with Fire Clearance. Living and dining rooms furniture were functional and in fair condition. 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: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

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 04/07/2023 05:49 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: RESIDENCE IV, THE	FACILITY NUMBER: 405802295
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2023

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
1 2 3 4	Based on record review and interviews, the licensee did not comply with the section cited above in 10 out of 10 training records which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	Licensee will conduct 10 hours of staff on-going training per employee by 4/14/23. Licensee will send CCL the training certificates by end of day 4/14/23.

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 4 out of 10 staff did not have records of tuberculosis tests completed prior to employment which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	Licensee will records of tuberculosis tests to CCL by 4/14/23.

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: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/07/2023 05:49 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: RESIDENCE IV, THE	FACILITY NUMBER: 405802295
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on record review and interviews, the licensee did not comply with the section cited above in that licensee and records indicate emergency disaster drills have not been conducted since licensure which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	Licensee has committed to conducting an emegency disaster drill by 4/14/23 and quarterly drills thereafter. Licensee will send the training sign-in sheet to CCL by 4/14/23.

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: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

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: RESIDENCE IV, THE	FACILITY NUMBER: 405802295
	VISIT DATE: 04/07/2023

NARRATIVE

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LPAs reviewed 5 staff files with required forms were present: Personnel Record, 1st Aid & CPR, Fingerprint clearance and associations, Criminal Records Clearance, however, four staff were missing the Health screenings with TB results.

LPAs reviewed Staff Training Records. Training records were present with a total of 17 hours completed and missing 3 hours annually. Additionally, required training included only one 1 hour of medications and 3 hours of hospice and did not meet the minimum 20 hours of annual training.

LPAs reviewed 2 residents’ medications, medication reviewed were current on the CSMDR and MAR for 2 residents in care. No issues with medications and records.

There are no bodies of water on the premises. There is plenty of lighting available for the safety of the residents. The kitchen area was sufficiently stocked with two-day perishable and seven-day non-perishables. Snacks and beverages are available for residents in the facility when they want. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Sharps and knives are locked in a drawer in the kitchen.
The 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 needed.

The bathrooms were checked for cleanliness and proper operation. The hot water temperature measured at 110.6 F in bathroom #1, bathroom #2 at 110 F, and bathroom #3 at 109.4 F. Towels and washcloths are not shared. Residents have a sufficient amount of supplies for personal hygiene. Soap and toilet paper are provided by the Licensee. Grab bars are secured in toilet and shower areas. Showers have non-slip mats.
Resident records were reviewed for requirements and legibility: LPA reviewed 6 residents’ files for current Medical Assessments with TB results, Current Appraisal Needs and Service plans which were updated, signed Admission Agreements, consent forms, and immunization records. Pre-appraisals were missing from resident files. Planned activities are offered to residents in care.
Infection control was evaluated, and the facility is in compliance.

Exit interview conducted, Deficiencies cited, Technical Violations issued, and the report and appeal rights given to the licensee.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

LIC809 (FAS) - (06/04)

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