405850038-8-16-2023-29-AS-RDLN-CURVYC-20230816165055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850038
Report Date: 08/16/2023
Date Signed: 08/16/2023 04:51:36 PM

Document Has Been Signed on 08/16/2023 04:51 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:	ARROYO GRANDE HOME		FACILITY NUMBER:	405850038
ADMINISTRATOR:	GUADALUPE RAMIREZ HERNANDE		FACILITY TYPE:	735
ADDRESS:	2119 LOPEZ DR		TELEPHONE:	(805) 473-5784
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY: 4		CENSUS: 4	DATE:	08/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Guadalupe Ramirez, Administrator		TIME COMPLETED:	05:00 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 1:45 pm to conducted a 1 year annual visit to the facility above. LPA met Administrator Guadalupe Ramirez 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, and Emergency Disaster 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 & Environment Safety: The facility is a 4 bedroom and 2 bathroom currently occupying 4 residents and employs 9 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-slip bottoms. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions, the front door gravel walkway needs the gravel leveled out so it will not pose a danger to clients in care. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to clients in care locked in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a front yard for client use with plenty of shade. The facility has telephone and internet service for client use. Water temperature was not checked on this visit and will be done on the annual continuation visit. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

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: ARROYO GRANDE HOME	FACILITY NUMBER: 405850038
	VISIT DATE: 08/16/2023

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. The facility is equipped with exiting door alarms and window alarms.

Staffing: The facility employes 8 staff and 1 Administrator. Staff records are kept confidential. LPA will return at a later date to review staff files for required documentation.

Personnel Records & Training: The facility keeps confidential files for each staff member. LPA will return at a later date to review all staff training records.

Clients Rights: All require postings were posted in the common area of the facility. Personal rights of 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 in the staff office. 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 client confidentially. LPA will return at a later date to review clients files. The facility does submit incident reports when needed.

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 clients in care. No clients in care are currently on a modified diets prescribed by a physician. 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.

Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

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: ARROYO GRANDE HOME	FACILITY NUMBER: 405850038
	VISIT DATE: 08/16/2023

NARRATIVE

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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 with privacy.

Incidental Medical Services: Facility provides transportation or arranges transportation to medical and dental appointments when needed. LPA will review medication records at a later date.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 07/25/2023. 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 9 staff have current CPI Non-Violent Crisis Intervention Training Certificates. The facility is a hands off facility and does not use manual restraint or seclusion.

LPA will conduct interviews with staff and clients at a later date. LPA will return to the facility to complete the annual 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: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC809 (FAS) - (06/04)

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