405850036-9-21-2023-29-AS-RDLN-CVW323-20230921175117

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850036
Report Date: 09/06/2023
Date Signed: 09/21/2023 05:51:36 PM

Document Has Been Signed on 09/21/2023 05:51 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:	PABLO LANE HOME		FACILITY NUMBER:	405850036
ADMINISTRATOR:	SHANNON MACKENZIE		FACILITY TYPE:	735
ADDRESS:	340 PABLO LN		TELEPHONE:	(805) 723-5126
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY: 4		CENSUS: 4	DATE:	09/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Rafael Mendoza, Program Director		TIME COMPLETED:	06:00 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 arrived at 11:30am to conducted a 1 year annual visit to the facility above. LPA met with Program Director Rafael Mendoza and explained the purpose of the visit. Administrator Shannon Mackenzie arrived to assist in the annual visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Infection Control Plan to the department. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and waste baskets have tight fitting covers. Physical Plant & Environmental Safety: The facility is a 4 bedroom and 2 bathroom currently occupying 4 residents and employs 8 staff and 8 on call back up staff if needed. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in laundry room cupboards. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. Water temperatures were within regulation requirements. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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: PABLO LANE HOME	FACILITY NUMBER: 405850036
	VISIT DATE: 09/06/2023

NARRATIVE

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Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has exiting door alarms, window and screen alarms present and working. The facility has current liability insurance and expires on 10/01/2023. The facility is approved for a capacity of 4 Ambulatory.

Staffing: The facility employes 15 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 staff files for 1st AID/CPR, Finger print clearances, Applications, Health exam with TB results, Criminal Record statement and CPI certificates.

Personnel Records & Training: The facility keeps confidential files for each staff member. 4/5 staff had current 1st AID/CPR, Administrator will send LPA email with the updated card expiration date. Records were present and up to date. Initial and Annual Training requirements are being met. Medication Management 2023 Annual Training was completed with most staff and staff that did not complete are scheduled to complete next month.

Clients Rights - All require postings were posted in the common area of the facility. Personal rights and Persons with disabilities, Non-discrimination notice, and Theft and Loss policy. CCL Complaint poster is posted. The current license along with CCL reports and PIN's were posted. Visitation policy is posted at entry. Internet is provided to each client and each client is given confidentiality and privacy.

Clients Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS) are done as IPP and ISP and completed quarterly and annually, TB results, Personal Rights, and Safeguard for personal property and valuables. The Facility does handle cash resources for all 4 residents in care. LPA audited all 4 residents funds with ledgers, cash, and receipts all balancing. The facility Surety bond is current. Facility does submit incident reports to the department when required.

Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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: PABLO LANE HOME	FACILITY NUMBER: 405850036
	VISIT DATE: 09/06/2023

NARRATIVE

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Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 45 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. A menu is posted for residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices.

Health Related Services: Facility provides Centrally Stored Medications to all clients in care. First Aid is provided to clients in care. Clients medication records were reviewed, prescriptions had doctors orders, and PRN medications were checked for expiration date, the facility had an expired PRN medication that was not given to resident and it will be destructed with a new medication ordered.

Incidental Medical Services: Facility provides transportation to medical and dental appointments when needed. The medications records reviewed the facility uses the Medication Administration Record (MAR) and the Centrally Stored Medication and Destruct Record (CSMDR).

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 02/13/2023. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Emergency Intervention: All staff had valid CPI Non-Violent Crisis Intervention Training Certificates.

LPA conducted interviews with 2 Staff and 2 Residents.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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