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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802297
Report Date: 05/09/2023
Date Signed: 05/09/2023 03:57:01 PM

Document Has Been Signed on 05/09/2023 03:57 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:OPTIONS - LEGATO HOMEFACILITY NUMBER:
405802297
ADMINISTRATOR:DEBRA BERTRANDOFACILITY TYPE:
735
ADDRESS:3750 LA LUZ RD.TELEPHONE:
(805) 464-4880
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 4CENSUS: 4DATE:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Kerri Smith, House Supervisor, and Tammy Peterson, House ManagerTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Chavez conducted an unannounced Annual/Required visit. LPA met with Kerri Smith, House Supervisor, and Tammy Peterson, House Manager, and explained the purpose of the visit. Also, in attendance was Jeff Edler, Tri-Counties Regional Center (TCRC), Quality Assurance Specialist.

LPA toured the facility with the house supervisor and TCRC. Facility is maintained in conformity with state fire marshal regulations. Smoke detectors and carbon monoxide detector functioning properly. Fire extinguishers (3) were located at the inside entranceway, the hall near the garage, and the hall near resident bedrooms. Extinguishers were fully charged and last inspected on 6/15/22. There are no pools or bodies of water at facility. No fire arms or dangerous weapons are located at facility. Hot water temperature measured between 115 F and 119 F degrees in resident bathrooms (3). All toilets and hand washing facilities are maintained in a safe, sanitary, operating condition. The facility is clean, safe, sanitary and in good repair for the safety and well-being of clients, employees, and visitors with the exception of two window screens needing repair at the kitchen and office. Each client is accorded safe, healthful, and comfortable accommodations, furnishings and equipment to meet his/her needs. LPA observed clients being treated with dignity and respect. There is a minimum 2-day supply of perishables and 7-day supply of nonperishable foods. Food is stored and prepared in a safe and healthful manner. Disinfectants, cleaning solutions and poisons are inaccessible to residents. Facility has adequate emergency supplies and first aid supplies. Facility temperature is 74 degrees Fahrenheit. Outdoor walkways are free from obstruction and the facility has outside areas for individuals to use. Centrally stored medication is kept secure in the locked office and inaccessible to clients. Medications are given as prescribed by doctors’ orders. The last emergency disaster drill was conducted on 4/6/23. LPA reviewed (5) staff files for criminal record clearances and associations, Health screening with TB results, and current First Aid/CPR. One out of five staff files reviewed did not have documentation showing results of a negative TB test. Deficiency cited. LPA reviewed (5) client files for current needs and services plans and signed admission agreements and personal rights. All files are in compliance.
Exit interview conducted, deficiency cited, and the report and appeal rights given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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 2
Document Has Been Signed on 05/09/2023 03:57 PM - It Cannot Be Edited


Created By: Darlene Chavez On 05/09/2023 at 02:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OPTIONS - LEGATO HOME
FACILITY NUMBER: 405802297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

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 one out of five staff files not documenting TB results which poses a potential health, safety or personal rights risk to persons in care..
POC Due Date: 05/16/2023
Plan of Correction
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Licensee will ensure TB results are sent to CCL for the staff not currently showing documentation of negative test. Send to CCL by 5/16/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
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