405809547-7-9-2021-29-AS-RDLN-C4RV9U-20210709161453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405809547
Report Date: 07/09/2021
Date Signed: 07/09/2021 04:15:43 PM

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:	OAKS AT NIPOMO, THE		FACILITY NUMBER:	405809547
ADMINISTRATOR:	DONAHUE VANDERHIDER		FACILITY TYPE:	740
ADDRESS:	177 MARY AVENUE		TELEPHONE:	(805) 723-5206
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY:	122	CENSUS:	DATE:	07/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Donahue Vanderhider, Administrator		TIME COMPLETED:	02:35 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 07/09/2021 at 11:15 AM. LPA met with Donahue Vanderhider, Administrator and explained the purpose of the visit. Administrator took LPA on 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, hand hygiene and masking. Visitor poster is on table outside of the facility entry point. All documentation is kept in binders at front desk. The entry station has hand sanitizer along with a thermometer. The facility has a several sitting areas thorough out the facility, signs are posted through out the facility reminding social distancing, hand hygiene, reporting of symptoms. Several areas are large enough for activities and exercise, all areas are spaced to accommodate as much space as possible for social distancing. All PPE supplies are kept in a staff room in cabinets accessible to all staff. Medications are kept in a locked medication room. The kitchen area was clean, safe and sanitary and well stocked with perishable and non-perishable foods to meet the regulation requirements. The dining area is large enough to accommodate distancing between residents when eating meals, signs are posted to remind social distancing and hand hygiene. . 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 is noted or any residents is showing any signs, symptoms or has a temperature. All required postings are hung in common areas of the facility. Facility provides residents with masks when leaving the facility on any outings into the community. Staff remind residents to wear masks in common areas of the facility. Housekeeping carts are well stocked with cleaning supplies and disinfectant. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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: OAKS AT NIPOMO, THE	FACILITY NUMBER: 405809547
	VISIT DATE: 07/09/2021

NARRATIVE

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All staff wear face coverings in the facility at all times. Facility has several areas for visiting inside and outside. Current visitation policies and procedures are being followed at the facility. The facility also offers virtual and telephone communications to residents in care. The Facility has hand sanitizer stations located thorough out the building. 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. Emergency Disaster plan is posted at the front desk and all agencies with telephone numbers are listed. Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverage when needed. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed positive cases of Covid-19. Facility is able to dedicate a single room and bathroom for resident so isolation can be arranged when and if needed. The facility has several restrooms for resident use. Restrooms are kept clean and well stocked with soap and paper towels, as well as signs are posted for hand washing. Facility apartments have restrooms. 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. Trash bins had tight fitting lids. Facility has plans for delivering medications and meals to any quarantined/isolation room. The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/or 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. Furniture has been moved around to accommodate social distancing for staff and residents. 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. Staff and resident records are kept in a locked room.
Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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: OAKS AT NIPOMO, THE	FACILITY NUMBER: 405809547
	VISIT DATE: 07/09/2021

NARRATIVE

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Laundry rooms are clean and sanitary and available for assisted living residents use. The memory care unit has delayed egress. Administrator opened exiting door so LPA could hear alarm and see if staff came to assist, alarm sounded and staff did come to assist. Memory care dining tables and chairs are spaced out to accommodate as much room as possible between residents. Restrooms are stocked with soap, paper towels and signs for hand washing. Facility administrator and staff realize guidance changes frequently and the most up to date guidance and most stringent orders from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance.

No deficiencies observed during the visit and all infection control protocols are implemented and followed.

Exit interview completed and copy of report emailed to Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC809 (FAS) - (06/04)

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