405850052-2-15-2023-29-AS-DCHZ-CP3VZP-20230215155303

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850052
Report Date: 02/15/2023
Date Signed: 02/15/2023 03:54:16 PM

Document Has Been Signed on 02/15/2023 03:54 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:	PARK PLACE ASSISTED LIVING		FACILITY NUMBER:	405850052
ADMINISTRATOR:	BARNHILL, DIANA		FACILITY TYPE:	740
ADDRESS:	7500 PORTOLA RD		TELEPHONE:	(805) 591-9855
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	13	CENSUS: 12	DATE:	02/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:23 PM
MET WITH:	Diana Barnhill, Licensee/Administrator		TIME COMPLETED:	04:15 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	On 2/15/23 at 1:23 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Diana Barnhill, Licensee/Administrator, and explained the purpose of the visit. LPA toured the facility with licensee and observed the following: At 1:28 pm, the knife drawer in the kitchen was unlocked and containing sharps. This violates the regulation for care of persons with dementia. Deficiency cited. The facility has signage at the front door regarding the visitor policy and signage throughout the facility on infection control precautions. Screening, hand sanitizer and visitor log were available upon entry. The facility has seven single-occupancy resident rooms and three double-occupancy resident rooms. Each room includes an attached bathroom. Individual resident bathrooms and bathrooms in the common areas were stocked with soap and paper towels. Between 1:37 pm and 2:06 pm, the water temperatures in seven bathrooms were tested and recorded at 125.1F (Room 10), 127.4F (bathroom next to Room 10), 126.2F (Room 9), 130.7F (Room 4), 128.8F (bathroom next to Room 1), 88.7F (Room 2), and 120.5F (Room 3) degrees. Water temperatures are not in compliance of the regulatory 105F to 120F degrees. Deficiency cited. At 2:05 pm, Staff #1 (S1) was wearing their mask below their nose with residents in the facility. The facility did not protect the personal rights of residents in care to be able to receive safe and healthful accommodations in that the facility staff failed to wear face coverings properly while providing care and supervision to residents in care. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions. Deficiency cited. The facility has two fire extinguishers, one located in the hall next to the laundry and the other in the hall near the resident tv area. Both are fully charged and were inspected on 8/23/22. At 2:15 pm, LPA conducted the Infection Control mitigation module with the licensee. Exit interview conducted, deficiencies cited, and the report and appeal rights emailed to the licensee.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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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Document Has Been Signed on 02/15/2023 03:54 PM - It Cannot Be Edited

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: PARK PLACE ASSISTED LIVING	FACILITY NUMBER: 405850052
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on testing, the licensee did not comply with the section cited above in seven bathrooms whose water temperatures were recorded at 88.7F degrees and between 120.5F and 130.7F degrees which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2023
	Plan of Correction
1 2 3 4	Licensee will adjust the water temperatures to comply with the regulation, take videos of each bathroom not in compliance and send videos to LPA by end of day 2/16/23.

Type A

Section Cited

CCR

87468.1

87468.1 Personal Rights. Residents have the right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the facility failed to ensure Staff #1 was wearing face coverings properly which poses an immediate health, safety and personal rights risk to residents in care.
	POC Due Date: 02/16/2023
	Plan of Correction
1 2 3 4	Licensee will counsel Staff #1 regarding infection control policies and send CCL a copy of the written, signed and dated counseling letter by 2/16/23.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/15/2023 03:54 PM - It Cannot Be Edited

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: PARK PLACE ASSISTED LIVING	FACILITY NUMBER: 405850052
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)(1)

87705(f)(1) Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia, (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the kitchen drawer with knives/sharps was unlocked which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/22/2023
	Plan of Correction
1 2 3 4	Licensee immediately locked the knives drawer. Licensee has committed to locking the knives in a metal box that will be stored above the refrigerator in a locked cabinet. Licensee will send a photo to CCL by 2/22/23 showing the newly stored knife location.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

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