405802295-4-25-2024-29-AS-EMIR-D4NU32-20240425151250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802295
Report Date: 04/25/2024
Date Signed: 04/25/2024 03:13:08 PM

Document Has Been Signed on 04/25/2024 03:13 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
WOODLAND HILLS N.ASC, 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: 56	DATE:	04/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Meynard Marcos		TIME COMPLETED:	03:22 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) Miller arrived at 9:12 am to conduct a 1 year annual visit to the facility above. LPA met with administrator, Meynard Marcos and 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 a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectant spray and cleaners stored in garage. 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). There were trash cans in garage without a tight-fitting lid that contained soiled gloves and bed pads, administrator immediately discarded contents of the trashcan and will remind staff to discard trash properly. Physical Plant & Environment Safety: LPA Miller observed the main bathroom toilet seat was not in good repair. Administrator showed LPA the new seat and will replace it today. There is water damage to the wall near shower revealing old blue paint. Administrator advised that he will repaint the wall. LPA also observed that heating vent requires cleaning, as there is a significant amount of dust accumulated. The kitchen door leading to the garage needs cleaning and cabinets and walls have an accumulation of dust and cobwebs that need cleaning. LPA also observed microwave had food splatter and needed cleaning. The area above the stove needs cleaning of grease and food splatter. The fireplace mantel in the living room also needs dusting. LPA observed debris on floors in a bedroom and kitchen. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: RESIDENCE IV, THE	FACILITY NUMBER: 405802295
	VISIT DATE: 04/25/2024

NARRATIVE

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LPA observed damage to wall near large window in dining room. Administrator stated that damage was due to a wheelchair and will patch the wall as soon as possible. Dining room furniture has significant amount of cat hair on dining room chairs, and couch in living room has significant damage due to cat scratching furniture. Administrator advised that he will use a slip cover over the couch.

The fire extinguisher was purchased on June 5, 2022 and is charged and Administrator will replace today. The facility has 6 resident bedrooms,1 staff bedroom and 3 bathrooms currently occupying 6 residents. The staff bedroom is not included on the facility sketch. The facility has smoke and carbon monoxide detectors that were tested. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant and cleaning solutions are inaccessible to residents in care and stored in the garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use.

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 July 11, 2024. The facility is approved for a capacity of 6. The fire clearance is granted for 6 non-Ambulatory. Hospice is approved for 4.

Staffing: The facility currently employs 7 full time staff, and 1 administrator. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements. However, one staff member does not have an application on file and will completed on May 6, 2024. Administrator Certificate expires April 10, 2025.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2023.

Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: RESIDENCE IV, THE	FACILITY NUMBER: 405802295
	VISIT DATE: 04/25/2024

NARRATIVE

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Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, LIC. 602A Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms. Medical Assessments and Appraisal Needs and Services are not current, but will be provided May 6, 2024.

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 40 degrees or lower. All food is covered, stored, and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies.

Incidental Medical Services: Facility provides transportation or assist 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). LPA reviewed residents medications, no labels were altered, no medications were expired and all medications were kept in their original containers.
Disaster Preparedness: The current emergency disaster forms were posted. The facility last conducted a quarterly disaster drill March 20, 2024. 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.

Residents with Special Health Needs: The facility does accept dementia residents in care. The facility has 2 self latching gates on side of the home. The facility currently has 4 hospice residents in care. The facility does not currently have residents receiving Home Health services. The facility does not have delayed egress, locked doors or gates. Exit door alarms are working.

Exit interview conducted and copy of report issued to administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

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