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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802300
Report Date: 01/04/2024
Date Signed: 01/04/2024 03:01:57 PM


Document Has Been Signed on 01/04/2024 03:01 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:HOPE ASSISTED LIVINGFACILITY NUMBER:
405802300
ADMINISTRATOR:CASTANIAGA, JANELYNFACILITY TYPE:
740
ADDRESS:1023 SLEEPY HOLLOWTELEPHONE:
(805) 717-4578
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 6DATE:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Licensee - Janelyn CastaniagaTIME COMPLETED:
03:15 PM
NARRATIVE
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At 11:00am on 01/04/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with Licensee - Janelyn Castaniaga announced who he is and the reason for the visit.
This facility is has 6 resident bedrooms and 3 resident bathrooms down stairs. There are 4 resident bedrooms and two resident bathroom in the back hall of the facility and 2 resident bedrooms and 1 resident bathroom on the west side of the facility. The bathroom in the back east side of the facility was lacking a non skid mat [873903(e)(5)], and the toilet was not operational [87303(e)(5)] for "about 30 days" according the Licensee, and was not operational when LPA attempted to flush it on the inspection tour. Citation was issued for both violations. LPA toured the entire facility and found the smoke detectors to be in all rooms and functioning and the carbon monoxide detector to be in the back hallway and functioning properly. Fire extinguisher was currently tagged and in the green pressure range. All exits and walkways were free and clear of debit. LPA observed at least 2 days of perishable foods and at least 7 days of non-perishable foods on hand for six residents. LPA observed all rooms to have furnishings, linins, and lighting required by regulation. LPA observed facility has a complete first aide kit. LPA noted that the upstairs has a baby gate at the base of the stairs and there an additional 4 bedrooms and 2 bathroom which are all staff bedrooms and bathrooms.
LPA conducted a sample inspection of resident and staff files. LPA noted that resident files are updated and complete and all staff files are completed with current CPR and 20 hours of annual training with 8 hours of dementia training for each staff file reviewed. LPA conducted a sample medication audit. LPA noted that the review of the centrally stored medication record did not reveal any violations or citations.
Licensee and LPA conducted a full review of the annual control tools modules. LPA noted that only two type B violations were as noted above. At the time of writing this report Licensee had obtained a non skid mat for bathroom 3 and LPA will clear that Plan of Correction (POC). No other technical, violations, or citations were issued as a result of this full annual inspection and full care tools review.

Exit interview, report read, violations cited, appeal rights, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
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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Document Has Been Signed on 01/04/2024 03:01 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: HOPE ASSISTED LIVING

FACILITY NUMBER: 405802300

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
LIC809 (FAS) - (06/04)
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