405802555-5-20-2022-29-AS-RDLN-CELTEP-20220520144017

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802555
Report Date: 05/20/2022
Date Signed: 05/20/2022 02:41:12 PM

Document Has Been Signed on 05/20/2022 02:41 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:	SOUTHLAND HOME		FACILITY NUMBER:	405802555
ADMINISTRATOR:	KATHYRINE VALDEZ		FACILITY TYPE:	740
ADDRESS:	804 SOUTHLAND ST		TELEPHONE:	(805) 929-5096
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY: 4		CENSUS: 4	DATE:	05/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Michelle		TIME COMPLETED:	02:45 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) De Leon conducted an on site 1 year infection control annual visit to the facility above on 05/20/2022 at 11:45 AM. LPA met with Staff Nayrani Mendoza and explained the purpose of the visit. LPA took a physical plant tour of the facility. The facility has submitted a mitigation plan to the department and it has been approved. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening. All documentation is kept on a clipboard and in binders. The entry station has hand sanitizer along with a thermometer and additional PPE if needed. The facility has a large activity room, a dining room for dining, and a living area, all areas are spaced to accommodate as much space as possible for social distancing. The facility has a large covered patio for resident use. All additional equipment and PPE supplies are kept in the staff office. Medications are kept in a locked medication cabinet in kitchen pantry. The staff screen residents for symptoms and temperature 1x's a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or have a temperature. Signs are posted on the front door, entry area and walls in common areas regarding Covid-19. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility have areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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 05/20/2022 02:41 PM - It Cannot Be Edited

Created By: Rachael De Leon On 05/20/2022 at 01:24 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: SOUTHLAND HOME	FACILITY NUMBER: 405802555
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(a)

Other Provisions

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above the facility does not have a valid administrator or manager present at the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/27/2022
	Plan of Correction
1 2 3 4	Licensee agreed to appoint a valid administrator to be present at the facility during normal business hours and designate a manager to fill behind when an administrator is not present. Send the following forms to CCL LIC 500, LIC 501, LIC 308, Valid Administrator Certificate, and a Board Resolution appoitnting new administrator with an additional LIC 308 for a manager to be present when Administrator is absent.

Type B

Section Cited

HSC

1569.695(d)

Other Provisions

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above the emergency plan LIC 610E (10/030 signed and dated 10/01/2015 is no longer valid and requires to be updated which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2022
	Plan of Correction
1 2 3 4	Licensee agreed to update and submit a new LIC 610 Emergnecy Disaster Plan to CCL and post in the facility.

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:

Rachael De Leon

LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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

FACILITY NAME: SOUTHLAND HOME	FACILITY NUMBER: 405802555
	VISIT DATE: 05/20/2022

NARRATIVE

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Emergency Disaster plan is posted but is not up to date, last updated LIC 610E (10/03) signed and dated 10/01/2015, this form is required to be up to date and a new form has been released by the department. House Manager is in charge of infection control and provides training and education to staff, residents and visitors. House Manager is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals and will not work with other negative individuals until cleared by Health Department to do so. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. The facility has 4 resident bedrooms and 2 resident bathrooms and they are disinfected after use. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room. The facility has proper cleaning and disinfectant sprays. Facility has a plan in place for when and whom to notify in an outbreak or other emergencies. House Manager will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in cabinets in the staff office. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. The facility is in a current outbreak and staff do not have N95 fit testing certifications. Administrator on record is not currently the administrator of the home and no staff have a valid administrators certificate or designee form on file. Fire extinguishers are charged and inspected annually.
Exit interview completed, deficiencies cited, copy of report and appeal rights emailed to Administrator/Licensee.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC809 (FAS) - (06/04)

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