405850174-7-28-2023-29-AS-RDLN-CU74GB-20230728190516

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850174
Report Date: 07/28/2023
Date Signed: 07/28/2023 07:55:50 PM

Document Has Been Signed on 07/28/2023 07:55 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:	GARDEN HOUSE MORRO BAY		FACILITY NUMBER:	405850174
ADMINISTRATOR:	BRETT K. ALLAN		FACILITY TYPE:	740
ADDRESS:	480 MAIN ST		TELEPHONE:	(805) 772-7181
CITY:	MORRO BAY	STATE: CA	ZIP CODE:	93442
CAPACITY:	15	CENSUS: 15	DATE:	07/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Rebecca Michel, Administrator		TIME COMPLETED:	07:15 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	Licensing Program Analyst (LPA) De Leon arrived at 10:30 am to conducted a 1 year annual visit to the facility above. LPA met Administrator Rebecca Michel and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Mitigation Plan, Infection Control Plan, Emergency Disaster Plan. The facility has a sign in and out clipboard for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and waste baskets have tight fitting covers. Physical Plant & Environment Safety: The facility has 14 bedroom and 4 bathroom for resident use currently occupying 15 residents and employs 18 staff. 1 restroom is designated for staff and visitors. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. All pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in laundry room. The laundry room has a working washer and dryer. The facility has sufficient space inside and outside for activities and visiting. The facility has a courtyard for resident use with an umbrella for shade and self closing, self latching locked gate with coded entry or exit and delayed egress.. The facility has telephone and internet service for resident use. The facility has 5 doors with delayed egress. The facility has three siting areas through out the facility for resident use. 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: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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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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: GARDEN HOUSE MORRO BAY	FACILITY NUMBER: 405850174
	VISIT DATE: 07/28/2023

NARRATIVE

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Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 09/22/2023. The facility is approved for a capacity of 15 Non- Ambulatory of which all may be bedridden and a Hospice waiver for 8 residents. The facility is in compliance with these requirements.

Staffing: The facility employes 18 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 random staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. One staff did not have health screening on file. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate.

Personnel Records & Training: Staff training records were reviewed on 5 randomly chosen staff and those staff had 20 plus hours of training for 2023 meeting all required training topics. Administrator Certificate expires on 07/18/2024.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. The Facility does not handle cash resources for any of the residents in care. Facility does submit incident reports to the department when required.

Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster is posted in the entryway of the facility and LTCO poster was posted in the common area. The current license along with CCL reports and PIN's were posted in the front office area. Visitation policy is posted at entry. Internet is provided to residents with confidentiality and privacy.

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: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: GARDEN HOUSE MORRO BAY	FACILITY NUMBER: 405850174
	VISIT DATE: 07/28/2023

NARRATIVE

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Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. The kitchen has two closing gates to keep dementia residents safe.

Incidental Medical Services: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA observed medications where start dates were written on the labels and informed Administrator the facility can not write on the label and can use stickers on the top or bottom of the bottles.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drill and records were reviewed for both quarters of the 2023 year. The fire extinguishers were charged and last inspected on 07/05/2023. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked and in accessible to residents in care. The facility does have delayed egress. The facility does not currently have residents with oxygen. The facility has 3 hospice residents in care. Hospice care plans are kept on file and up to date. The facility does not currently have any residents on Home Health services.

LPA conducted interviews with 3 Staff and 3 Residents.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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