405850037-7-14-2023-29-AS-RDLN-CTQ2GJ-20230713172313

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850037
Report Date: 07/13/2023
Date Signed: 07/14/2023 11:09:51 AM

Document Has Been Signed on 07/14/2023 11:09 AM - 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:	LA LOMA HOME		FACILITY NUMBER:	405850037
ADMINISTRATOR:	JUSTIN A PENROD		FACILITY TYPE:	735
ADDRESS:	1151 LA LOMA DR		TELEPHONE:	(805) 723-5104
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY: 4		CENSUS: 4	DATE:	07/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Justin Penrod, Administrator		TIME COMPLETED:	05:30 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 9:15 am to conducted a 1 year annual visit to the facility above. LPA met Administrator Justin Penrod and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Mitigation Plan, Infection Control Plan, Emergency Disaster Plan and provide plans to the department. The facility has a sign in and out binder for visitors at entry with hand sanitizer and symptom screening. 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. New clients are tested and negative results received before residing in the facility. 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 & Environment Safety: The facility is a 4 bedroom and 3 bathroom currently occupying 4 residents and employs 8 staff. 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 clients comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to clients in care locked in closet off hallway. The facility has sufficient space inside and outside for activities and visiting. The facility has a enclosed backyard for client use with plenty of shade. The facility has telephone and internet service for client use. Water temperature were within regulation requirements and facility checks and keeps a monthly log of temperatures.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

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: LA LOMA HOME	FACILITY NUMBER: 405850037
	VISIT DATE: 07/13/2023

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 current liability insurance and expires on 10/01/2023. The facility is approved for a capacity of 4 Ambulatory.

Staffing: The facility employes 8 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 staff files and all required documents were present.

Personnel Records & Training: The facility keeps confidential files for each staff member. All staff had current 1st AID/CPR along with required annual training.

Clients Rights - All require postings were posted in the common area of the facility. Personal rights and Persons with disabilities, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster is posted at entry. 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 clients in care. LPA audited all 4 clients funds with ledgers, cash, and receipts. The facility Surety bond is current. Facility does submit incident reports to the department when required.

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 40 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 clients in care. Modified diets prescribed by a physician are followed for those clients 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.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

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: LA LOMA HOME	FACILITY NUMBER: 405850037
	VISIT DATE: 07/13/2023

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Health Related Services: Facility provides Centrally Stored Medications to all clients in care. First Aid is provided to clients in care. Staff has current 1st Aid/CPR certificates on file. Clients medication records were reviewed, prescriptions had doctors orders, and PRN medications were checked for expiration.

Incidental Medical Services: Facility provides transportation to medical and dental appointments when needed. The medications records reviewed.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 03/29/2023. 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 have current CPI Non-Violent Crisis Intervention Training Certificates.

LPA conducted interviews with 2 Staff and all 4 Clients were out of the facility at the time of visit.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC809 (FAS) - (06/04)

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