405809547-7-26-2022-29-AS-RDLN-CGQ25K-20220726170539

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405809547
Report Date: 07/26/2022
Date Signed: 07/26/2022 05:06:33 PM

Document Has Been Signed on 07/26/2022 05:06 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:	OAKS AT NIPOMO, THE		FACILITY NUMBER:	405809547
ADMINISTRATOR:	TRACY S. FLAHERTY		FACILITY TYPE:	740
ADDRESS:	177 MARY AVENUE		TELEPHONE:	(805) 723-5206
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY:	122	CENSUS: 109	DATE:	07/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Tracy Flaherty, Administrator		TIME COMPLETED:	02:05 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 (LPA) De Leon conducted an on site 1 year infection control annual visit to the facility above on 07/26/2022 at 11:15 AM. LPA met with Tracy Flaherty, 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 facility is currently in response with San Luis Obispo County Health Department (SLO DPH). All current recommendations are being followed. 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. Activities are being conducted outside per SLO DPH. Activities have been modified to individuals or small groups with social distancing. The facility has several areas large enough to accommodate activities and exercise, all areas are spaced for social distancing. Congregated dining is currently closed per SLO DPH. 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 Administrator will have two seats per table when dining opens back up and all areas are cleared by SLO DPH. Residents are currently being served in rooms. 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: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

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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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: 07/26/2022

NARRATIVE

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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 are showing any signs, symptoms or have 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. On today's visit at 12:00 PM a credible witness (W1) approached LPA and Administrator with a deficiency, W1 observed staff 1 (S1) transporting resident in van with a mask but it was pulled down under the chin around 11:10 AM.
Facility has several areas for visiting inside and outside. Current visitation policies and procedures set by SLO DPH are being followed at the facility with outside visitation and inside visitation with full PPE only. 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. Housekeeping carts are well stocked with cleaning supplies and disinfectant. 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. 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. 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: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

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: 07/26/2022

NARRATIVE

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Signs are posted on any room with quarantine or isolated individuals. PPE supplies are located right outside those rooms. Facility has a 30 day supply of PPE on hand. Trash bins had tight fitting lids. Facility has plans and is able to deliver medications and meals to any quarantined/isolation room. The facility has proper cleaning and disinfectant sprays. Facility Administrator's notifies proper agencies to report outbreaks 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. Laundry rooms are clean, sanitary and available for assisted living residents use. The memory care unit has delayed egress. 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.

Exit interview completed, deficiency cited, civil penalty assessed, copy of report and appeal rights emailed to Administrator. Administrator will sign and return report to CCL by mail.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/26/2022 05:06 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: OAKS AT NIPOMO, THE	FACILITY NUMBER: 405809547
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87468.1(a)(2)

Personal Rights 87468.1(a)(2) (a)Residents in all residential care facilities for the elderly shall have all the following personal rights: (2)To be accorded safe, healthful, comfortable accommadations, furnishings, and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on W1 observation the licensee did not comply with the section cited above in S1 was transporting resident in facility van with mask down below S1's chin which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/27/2022
	Plan of Correction
1 2 3 4	Administrator agreed to re-train all staff on infection control and mask wearing, provide training docuemnts with staff signatures to CCL.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

LIC809 (FAS) - (06/04)

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