405850147-3-9-2023-29-AS-MJES-CPRQXZ-20230309113419

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850147
Report Date: 03/22/2021
Date Signed: 03/09/2023 11:34:50 AM

Document Has Been Signed on 03/09/2023 11:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ALL SEASON CARE		FACILITY NUMBER:	405850147
ADMINISTRATOR:	ESTOQUE, ANALYN M		FACILITY TYPE:	740
ADDRESS:	1637 LEAH WAY		TELEPHONE:	(805) 234-2500
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	6	CENSUS: 0	DATE:	03/22/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:12 AM
MET WITH:	Analyn Deliema/Licensee		TIME COMPLETED:	12:15 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	At 9:00am on 03/22/2021, Licensing Program Analysis (LPA) Mark Jeffries conducted an announced pre-licensing visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s pre-licensing visit was conducted via FaceTime with Analyn Deliema. LPA conducted FaceTime video tour of facility. The outside grounds appeared to be free of obstructions and hazards. The gate on the south side of the facility was equipped with a self latching gate and a auditory delayed egress device was added to the gate. There were two storage sheds both equipped with padlocks and secured. The back side yard. There is seating with shade in the back yard. There is a fence on the North side of the back yard to close off access to the North side gate and entrance to the garage. Physical Plant: The facility is a 5 bedroom, 4 bathroom, with a living room, staff area, small activity area, kitchen, small laundry room and long hallway. There are two filing cabinets in the staff area that have keyed locks where confidential files can be stored and intake medication can be stored according the the licensee. The main medication storage is a key and lock cabinet in the kitchen area next to the refrigerator. The general appearance of the facility appears to be clean and will maintained. The chemical products are kept under the sink in the kitchen and in the cabinet in the laundry room in a locked closet above the washer and dryer. There is a door that is kept locked at all time that separates the laundry room and second door that leads to the garage. These door are kept locked at all times. The garage has storage of emergency food and furniture Bedrooms: There are 4 single occupancy rooms and one double occupancy room. All rooms have the appropriate amount of drawers and storage, single beds with spring mattresses, linin, and mattress pads. Bathrooms: There are 4 bathrooms for 6 residents, each bathroom has a shower/tub combination. The grab bars are securely fastened non-slip-skid mats are present in all showers. LPA advised Licensee of water temperature regulations of 105-120(f). Supplies:* LPA observed a full linin closet with ample linin supplies and hygiene supplies to support 6 residents. *CONTINUE on LIC809-C*

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

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: ALL SEASON CARE	FACILITY NUMBER: 405850147
	VISIT DATE: 03/22/2021

NARRATIVE

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Food Service: All appliances appeared to be clean and in good working order. Storage of cleaning chemicals as described above. Trash can in kitchen area had a tight fitting lid. LPA observed sufficient amount of utensils and dishware in good condition and sharps were stored in a keyed locked drawer in the kitchen. There was more than a seven day supply of Non-perishable foods and no residents at this time as LPA advised Licensee of the two days of perishables once resident occupy.
Records:. There are two filing cabinets in the Staff Office area both have keyed locks for confidential storage.
Administration: Emergency plans were posted in the hallway at the entrance door to the left as you walk into the facility. All required posting per 87468(c) were observed by LPA. Activities: LPA observed an inn table with several board games, puzzles and books for a variety of resident activities. There is ample space for 6 resident to participate in normal activities and keep social distancing in the living room and the activities area.
Dementia: LPA observed delayed egress devices on all exits and the north exterior fence. LPA did hear the several of the auditoria devices in working when doors would open and close. With the exception of the north fence (single battery powered audible alarm) all audio door alarms are managed through a central alarm system and each door alarm has to be cleared by the main control panel in the living room area. The system is serviced by MACE SECURITY with a card and service contact number located on the main control panel. There is also a manual fire alarm lever just below the main alarm control panel. LPA observed a clear lock box over the facility temperature control panel located in the hallway. LPA observed the removable knobs of the stove. The door that access the laundry room is to remain locked at all times. There are no bodies of water and no firearms located at this facility. LPA advised Licensee in a review of RCFE Regulations 87705.

LPA completed the RCFE Pre-Licensing inspection checklist and did not have any objections with licensing at this facility.

Exit interview conducted, a hard copy of report was provided via email for signature and return by mail to LPA.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

LIC809 (FAS) - (06/04)

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