405850222-2-4-2022-29-AS-DCHZ-CBC2FV-20220204162210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850222
Report Date: 02/04/2022
Date Signed: 02/04/2022 04:22:56 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:	LIFETOUCH THE ELEGANT LIVING RESIDENTIAL HOME CARE		FACILITY NUMBER:	405850222
ADMINISTRATOR:	AQUINO, AMELITA I.		FACILITY TYPE:	740
ADDRESS:	1934 TULIPWOOD DRIVE		TELEPHONE:	(805) 878-3409
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	6	CENSUS: 5	DATE:	02/04/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:04 AM
MET WITH:	Amelita Aquino, Applicant		TIME COMPLETED:	01:30 PM

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At 11:04 am, Licensing Program Analyst (LPA) Chavez conducted a scheduled pre-licensing visit to the facility above. LPA met with Amelita Aquino, Applicant, and explained the purpose of the visit. Applicant took LPA on a tour of the facility. There are currently five residents being served at the facility and two staff currently. Applicant states she will be hiring an additional two staff upon licensure.

Medications: The facility has a locked medication cabinet in the dining room for resident medications.

Physical Plant: Facility is clean, sanitary, and in good repair with a couple of exceptions listed below. There is a living room, kitchen, laundry closet, four bedrooms, and three bathrooms. Bedrooms #1 and #4 have furniture to occupy two residents in each room. Bedrooms #2 and #3 are single occupancy rooms. Kitchen and laundry cleaning supplies are kept in a locked cabinet in the laundry closet near the kitchen. Bathroom cleaning supplies are in locked cabinets in the laundry room. Walls, ceilings, floors, and areas inside the facility are clean, painted and/or in good repair. There is a caregiver room which can only be accessed from the backyard and is a locked room.

A fire extinguisher is located in the dining room and was inspected on 2/04/22. Dual smoke and carbon monoxide detectors (5) are located in the hallway and in each bedroom and were tested and working properly. Doors and passageways are unobstructed. The facility does not keep firearms or ammunition on the premises. Bathrooms are kept clean and in good repair. Water temperature in the bathroom in Bedroom #1 registered at 117.3 F degrees, the hallway bathroom registered at 117.4 F degrees, and the bathroom in Bedroom #4 was recorded at 107.3 F. The facility maintains a comfortable temperature of 75 F degrees. All external doors have working delayed egress alarms.

Continued on 809-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022

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: LIFETOUCH THE ELEGANT LIVING RESIDENTIAL HOME CARE	FACILITY NUMBER: 405850222
	VISIT DATE: 02/04/2022

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The emergency exit plan is posted in the hallway. A current disaster and mass casualty plan are maintained in the facility. Resident Personal Rights are displayed. The CCLD reporting poster is posted on the wall in the living room entrance. Facility has a working phone with number 805-226-0994.

A first-aid kit, kit manual and supplies are maintained. Refrigerator is maintained at 32 F degrees and the freezer was recorded at -4 F degrees. Food storage and preparation areas are clean and appropriate for food preparation. All appliances are clean and operating properly. Food utensils, dishes, and glasses are clean and in good repair. All rooms are appropriately furnished for their intended use. The facility has a minimum seven days of non-perishable foods and three days of perishable items. There are no knives accessible to residents. Knives are kept in a locked drawer in the kitchen. Kitchen water temperature was tested at 115.7 F degrees.

Resident and staff records are maintained at the facility in a locked cabinet in the dining room. Hallway cabinets have a good supply of linens.

The facility has a two-car garage with a locked door going into to the garage from the house. The facility has a 2022 Honda Pilot to transport residents.

COVID screening was conducted on LPA upon entry to the facility. The facility has a table at entry with a thermometer, hand sanitizer, and visitor sign-in sheet. The facility has plenty of hand soap and paper towels in bathrooms.

No corrections needed at this time.

Exit interview conducted and report emailed to applicant.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022

LIC809 (FAS) - (06/04)

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