405850039-8-10-2022-29-AS-RDLN-CH6RY2-20220810132538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850039
Report Date: 08/10/2022
Date Signed: 08/10/2022 01:26:05 PM

Document Has Been Signed on 08/10/2022 01:26 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:	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:	08/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Staff Laura Leon		TIME COMPLETED:	01:30 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 conducted an on site 1 year infection control annual visit to the facility above on 08/10/2022 at 12:30 PM. LPA met with Staff Caregiver and explained the purpose of the visit. LPA spoke with Licensee/Administrator and she has completed an LIC. 308 to meet with staff in her absence today. Staff took LPA on a physical plant tour of the inside and outside 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 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. Signs are posted in the entry way, throughout the facility, in the residents bedrooms and bathrooms regarding Covid-19. 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. 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. 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: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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: OAK PARK MANOR	FACILITY NUMBER: 405850039
	VISIT DATE: 08/10/2022

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
26
27
28
29
30
31
32

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. Staff will use full PPE with N95 masks, face shields and/or googles 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. 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, and Covid-19 testing for all staff/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. Residents medication is delivered in bubble packs every 30 days to the facility. The facility ensures proper cleaning is done on all 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 are to 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: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2