405802300-12-9-2024-29-AS-MJES-DBSTM7-20241209135037

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802300
Report Date: 12/09/2024
Date Signed: 12/09/2024 01:51:42 PM

Document Has Been Signed on 12/09/2024 01:51 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 LIVING		FACILITY NUMBER:	405802300
ADMINISTRATOR/ DIRECTOR:	CASTANIAGA, JANELYN		FACILITY TYPE:	740
ADDRESS:	1023 SLEEPY HOLLOW		TELEPHONE:	(805) 717-4578
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY: 6		CENSUS: 5	DATE:	12/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Care Giver, Francisco Tiburcio		TIME VISIT/ INSPECTION COMPLETED:	01:27 PM

NARRATIVE

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At 9:02am on 12/09/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with Care Giver, Francisco Tiburcio, (S1) announced who he is and the reason for the visit. S1 called Licensee/Administrator and received verbal and video conference authorization from Licensee/Administrator to conduct full annual with S1 due to unavailability of Licensee/Administrator.

S1 and LPA conducted a physical tour of this facility which is a 6 resident bedrooms and 3 resident bathrooms down stairs. There are 4 resident bedrooms and two resident bathrooms in the back hall of the facility and 2 resident bedrooms and 1 resident bathroom on the west side of the facility. 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 five residents and staff. 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 full 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.

CONTINUED on LIC809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOPE ASSISTED LIVING	FACILITY NUMBER: 405802300
	VISIT DATE: 12/09/2024

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Licensee and LPA conducted a full review of the annual control tools modules. LPA noted that only two type B violations were as noted: Based on interview with S1, there were no awake staff during night shift due to “live-in” staffing, LPA noted that 2 of 5 residents that are currently residing at the facility have a diagnosis of Dementia, requiring awake staff overnight hours between 10pm and 6am; LPA noted that in a review of the facility Plan of Operation (POO) there was no information of dementia care for the facility’s POO information. No other 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.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/09/2024 01:51 PM - It Cannot Be Edited

Created By: Mark Jeffries On 12/09/2024 at 11:51 AM

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: HOPE ASSISTED LIVING	FACILITY NUMBER: 405802300
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(c)

Plan of Operation

(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in ] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/23/2024
	Plan of Correction
1 2 3 4	Licensee will provide dementia information as an ademdum to there plan of operations by 12/23/2024 to LPA by email.

Type B

Section Cited

CCR

87705(c)(4)(A)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview of S1 on 12/09/2024, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/23/2024
	Plan of Correction
1 2 3 4	Licensee will conduct staff training for all staff on 1hour of Dementia care training.Licensee will proved training records to LPA by emai before 12/23/2024.

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:

Mark Jeffries

LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC809 (FAS) - (06/04)

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