405850039-8-25-2021-29-AS-RDLN-C68SE2-20210825134802

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850039
Report Date: 08/25/2021
Date Signed: 08/25/2021 01:49:49 PM

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:	OAK PARK MANOR		FACILITY NUMBER:	405850039
ADMINISTRATOR:	MEFFERT, ASTRID		FACILITY TYPE:	740
ADDRESS:	1073 OLD OAK PARK ROAD		TELEPHONE:	(805) 540-1503
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	32	CENSUS: 19	DATE:	08/25/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Astrid Meffert, Administrator		TIME COMPLETED:	01:52 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 08/25/2021 at 11:00 AM. LPA met with Licensee Astrid Meffert and explained the purpose of the visit. Licensee took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening all staff, residents returning from an outing, and visitors wanting to come into the facility. All documentation is kept on a clipboard and filed in binder daily. The entry station has hand sanitizer along with a thermometer. The facility has a large living room area that is used for activities and exercise, all areas are spaced to accommodate as much space as possible for social distancing. Medications are kept in a locked medication cart in the dining area. The kitchen area has a dining area to accommodate some distancing between residents when eating meals. The staff screen residents for symptoms and temperature 1 x's a day and documentation is kept in residents file. Increased monitoring is conducted if any change of conditions are noted, any residents having signs, symptoms or a temperature. Signs are posted in the entry way, in the bathrooms and the bedrooms of residents regarding Covid-19 symptoms to report to staff, coughing and sneezing etiquette, hand hygiene, mask wearing and social distancing, and PPE donning and doffing. All required postings are hung in the entry way and common areas of the facility. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. 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: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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: OAK PARK MANOR	FACILITY NUMBER: 405850039
	VISIT DATE: 08/25/2021

NARRATIVE

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Facility has several areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. 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 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. Licensee is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility dedicated staff will be assigned to work with those quarantined/isolated individuals only. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. The facility has several restrooms for resident use, hand washing signs are posted and bathrooms are well stocked with paper towels and soap. Signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. PPE supplies are kept in the front house accessible to all staff. Facility has a 30 day supply of PPE on hand, supplies are audited and ordered regularly. Trash bins outside and in common areas have tight fitting lids. Facility has plans for delivering medications and meals to any quarantined/isolation room. The facility has proper cleaning and disinfectant sprays. The facility has not been fitted tested for N95 masks and LPA explained in an outbreak the facility would need to be wearing N95 and CAL OSHA requires fit testing of those masks. LPA's highly recommended Licensee look into testing for the N95 masks before an outbreak. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated, Covid-19 testing for all staff and 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. Activities have been modified to individuals or smaller groups with social distancing, activities are held in the dining room and outside patio area. Furniture has been moved around as much as possible to accommodate social distancing between staff and residents. 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: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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: OAK PARK MANOR	FACILITY NUMBER: 405850039
	VISIT DATE: 08/25/2021

NARRATIVE

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Residents medication is delivered in bubble packs every 30 day 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 locked in office. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed.

No deficiencies observed during the visit and all infection control protocols are implemented and followed.

Exit interview completed and copy of report emailed to Licensee.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC809 (FAS) - (06/04)

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