405802555-3-13-2023-29-AS-RDLN-CPVUUG-20230313155330

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802555
Report Date: 03/13/2023
Date Signed: 03/13/2023 03:53:54 PM

Document Has Been Signed on 03/13/2023 03:53 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:	KERYE A. MARTINEZ		FACILITY TYPE:	740
ADDRESS:	804 SOUTHLAND ST		TELEPHONE:	(805) 929-5096
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY:	4	CENSUS: 4	DATE:	03/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Neidra Leal, Back up Administrator		TIME COMPLETED:	04:05 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’s (LPA’s) De Leon and Jeffries arrived at 9:00 am and made an unannounced 1-year required annual visit to the facility above. LPA’s meet with Nerieda Leal and Ricardo Navarro, Back up's to Administrator and explained the purpose of the visit. LPA’s requested a staff roster, a resident roster, emergency and disaster plan, documentation of quarterly emergency drills. A tour of the physical plant was assessed, and the following was noted: LPA observed the license posted, covid signs, complaint poster, personal rights, LTCO poster, Bill of Rights and Right to Residential Council. The facility has 4 bedrooms, 3 bathrooms, kitchen, dining room, living room, activity room, laundry room, medication room, back yard enclosed with table, chairs and shade for resident use. Facility currently occupying 4 Residents and 9 staff. Physical plant was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, and all were in good condition. The facility maintains a comfortable temperature. The facility provides working telephones and on-line access for resident use. The dual smoke detectors and carbon monoxide detectors are hard wired and in bedrooms and common area. Fire extinguishers were last inspected 05/18/2022 and all show charged in the green. There are no issues with Fire Clearance. Living and dining rooms furniture were also checked for functionality and condition. The living rooms are clean, safe and sanitary along with the dining rooms. The side gates are no longer self-closing or self-latching. There are no bodies of water on the premises. There is plenty of outdoor lighting available for the safety of the residents. Continued on 809C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

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: SOUTHLAND HOME	FACILITY NUMBER: 405802555
	VISIT DATE: 03/13/2023

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The kitchen area was sufficiently stocked with two-day perishable and seven-day non-perishables. The sample menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers.
The Resident rooms have beds with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, night stand and enough lighting for each resident. Residents arranged the rooms the way they want them. There is enough linen available to change weekly or more if need.
The Laundry room is kept locked and all detergents and supplies are locked.
Towels and washcloths are not shared. Residents have a sufficient amount of supplies for personal hygiene. Soap, toilet paper and paper towels are provided by the Licensee. Grab bars are secured in toilet and shower areas. Showers have non-slip bottoms.
Resident records were reviewed for requirements and legibility: LPA reviewed 4 resident’s files for current Medical Assessments with TB, Current Appraisal Needs and Service plans (TCRC IPP) , and signed Admission Agreements. Planned activities are offered to residents in care.
Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 4 staff for criminal record clearances/associations, Health screening were not present in 2 of 4 files reviewed, TB results for all 4, current First Aid/CPR, caregivers/Med-tech annual training and Administrator Certificate expires 08/22/2024.
Medications are in a centrally stored and locked medication room, including over-the-counter medicines; Medications are properly labeled. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the residents’ doctor. Proper medication dispensing instruction are followed.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC809 (FAS) - (06/04)

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