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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850247
Report Date: 06/02/2022
Date Signed: 06/02/2022 10:52:04 AM


Document Has Been Signed on 06/02/2022 10:52 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:INGLESIDE BY THE LAKEFACILITY NUMBER:
405850247
ADMINISTRATOR:DAUGHERTY, NIKOLEFACILITY TYPE:
740
ADDRESS:9375 MOUNTAIN VIEW DRIVETELEPHONE:
(805) 460-6494
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 6DATE:
06/02/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Brett Allan, Applicant, and Zolton Soo, AdministratorTIME COMPLETED:
11:03 AM
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Licensing Program Analyst (LPA) Chavez conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Brett Allan, and administrator Zolton Soo. This is a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver has been requested.

The facility is a two story with residents residing only the first level and the licensee inhabiting the second level. At 9:18 am, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing the facility for zero (0) non-ambulatory residents; zero (0) ambulatory residents; and, six (6) bedridden residents. The facility has six (6) private resident bedrooms. All resident rooms have direct exits to the outside. The facility has a fire sprinkler system. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is not a staff room as night staff are awake on the NOC shift. All rooms were free of odors. All window screens were clean and maintained in good repair.
There is one (1) bathroom in the hallway which is designated as a staff bathroom. Three (3) resident bedrooms have attached bathrooms and there is a hall bathroom designated for Bedrooms #3, 4, and 5. The resident bathrooms have showers with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105*F and 120*F.

Continued on 809-C.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
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 3


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: INGLESIDE BY THE LAKE
FACILITY NUMBER: 405850247
VISIT DATE: 06/02/2022
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Resident records are stored in a filing cabinet in the office which is currently located in the kitchen. Staff records are located at Ingleside Assisted Living (facility #405850249) in a locked cabinet in the administrator’s office. Medications are centrally stored in a locked closet in the kitchen. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in a locked closet in the kitchen.

Kitchen knives are stored in a locked drawer in the kitchen. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. The trash can is in a cabinet. Kitchen, laundry and house cleaning supplies are stored in the locked kitchen and laundry rooms.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and family room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is a fireplace in the living room. It is screened and there are no tools. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility has emergency lighting, which included electronic flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There are three (3) fire extinguishers throughout the facility. They are fully charged and do not exceed the expiration date.

Continued on 809-C.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
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: INGLESIDE BY THE LAKE
FACILITY NUMBER: 405850247
VISIT DATE: 06/02/2022
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The laundry area is located outside in a closet in the backyard. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a storage closet in the hallway. Extra incontinence supplies are stored in resident rooms. There is a functioning telephone on the premises in the kitchen, phone number 805-460-6494. The emergency exiting plans/sketch are posted in all hallways and at the entrance. The emergency telephone numbers are posted in the hallways next to the emergency exit plans. Other required postings are posted in the hallway to Bedrooms #3, 4, 5, and 6.

The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the front of the facility with tables and chairs where residents can sit. The backyard is fenced and the front yard has parking. There is no gate to the parking area. The backyard is fenced with a locked gate. There is a three-car garage and a shed on the property which are not accessible to residents.

There are no items to be corrected prior to licensure.

Exit interview conducted and a copy of report emailed to applicant and administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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