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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850038
Report Date: 08/18/2023
Date Signed: 08/18/2023 02:59:58 PM

Document Has Been Signed on 08/18/2023 02:59 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 HOMEFACILITY NUMBER:
405850038
ADMINISTRATOR:GUADALUPE RAMIREZ HERNANDEFACILITY TYPE:
735
ADDRESS:2119 LOPEZ DRTELEPHONE:
(805) 473-5784
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY: 4CENSUS: 4DATE:
08/18/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Guadalupe Ramirez, AdministratorTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) De Leon arrived at 12:20 pm to conducted a case management annual continuation visit to the facility above. LPA met Administrator Guadalupe Ramirez and explained the purpose of the visit.

Staffing: The facility employes 8 staff and 1 Administrator. Staff records are kept confidential and locked in staff office. LPA reviewed 4 random staff files and 1 Administrator file. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for meeting the Continuing Education requirements, HIV/TB training completed and LPA verified Administrator on the ARF Certification list as pending.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff files had initial and annual training's, All staff had current First Aid/ CPR training, and current CPI training certifications.

Clients Rights: All require postings were posted in the common area of the facility. Personal rights of Persons with disabilities, Personal Rights, 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 confidential locked in staff office. 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) which facility utilizes the Individual Services Plan (ISP) and contains the same information and is completed annually, TB results, Personal Rights and Safeguard for property and valuables. The Facility does handle cash resources for all clients in care. Facility Surety Bond is current and expires 10/01/2023. LPA audited all four clients cash resources, ledger, receipts and balances were all present and correct. 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: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 08/18/2023
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Health Related Services: Facility provides Centrally Stored Medications to all clients in care. Medications are kept in a locked medication cart. Facility does not have any clients with prohibited or restricted health conditions. Doctor orders and prescriptions are present in client files, First Aid is provided to clients in care with privacy. Facility has a first aid kit and a sharps container.

Incidental Medical Services: Facility provides transportation or arranges transportation to medical and dental appointments when needed. LPA will review medication records the facility uses the Medication Administration Record (MAR) and the Centrally Stored Medication and Destruct Record (CSMDR)for all clients in care. All medications were reviewed, checked for expiration dates, and no medications labels were altered. The Administrator and additional staff complete destruct records and take medications to Rite Aid for destruction.

LPA conducted interviews with 1 staff, no other staff were at the facility during the visit, all 4 clients were at work program or on an outing at the time of the visit so unable to interview any clients in care.

Exit interview conducted and copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023
LIC809 (FAS) - (06/04)
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