405850247-5-16-2023-29-AS-DCHZ-CRVTRP-20230516145752

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850247
Report Date: 05/16/2023
Date Signed: 05/16/2023 02:59:27 PM

Document Has Been Signed on 05/16/2023 02:59 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:	INGLESIDE BY THE LAKE		FACILITY NUMBER:	405850247
ADMINISTRATOR:	DAUGHERTY, NIKOLE		FACILITY TYPE:	740
ADDRESS:	9375 MOUNTAIN VIEW DRIVE		TELEPHONE:	(805) 460-6494
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	6	CENSUS: 6	DATE:	05/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Nikole Daugherty, Administrator		TIME COMPLETED:	03:20 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) Chavez made an unannounced 1-year required annual visit to the facility above. LPA met with Nikole Daugherty, Administrator, and explained the purpose of the visit. LPA requested a staff roster, a resident roster, emergency and disaster plan, and documentation of quarterly emergency drills. Quarterly drills were conducted in December 2022 and March/April 2023. There is no documentation showing they were conducted prior to this. Deficiency cited. LPA toured the facility with the Administrator and the following was noted: LPA observed the license posted, licensing reports, personal rights, non-discrimination notice, LTCO poster, CDSS Complaint Poster, Bill of Rights and Right to Residential Council. The facility has 6 bedrooms and 5 bathrooms, a kitchen, dining room, living room, activity room, and a storage garage. Medications are kept in a locked cabinet in the kitchen. Physical plant was check for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, and all were in good condition. The facility maintains a comfortable temperature. The facility provides a working telephone for resident use. Smoke and carbon monoxide detectors were tested and operational. Fire extinguishers (3) are located in the hall by bedroom 5, at the front entryway, and in the back patio. They were last inspected 4/24/23 and are charged in the green. There are no issues with Fire Clearance. The facility has cameras inside and outside throughout the facility. Living and dining room furniture were also checked for functionality and condition. The living room and dining room are clean, safe and sanitary. Courtyard of the facility has outdoor furniture, with a covered shaded area for residents in the front and back yards. The facility has a fenced swimming pool with locked gates. There is plenty of outdoor lighting available for the safety of the residents. External gates have latches and working properly. 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: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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 05/16/2023 02:59 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: INGLESIDE BY THE LAKE	FACILITY NUMBER: 405850247
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews, the licensee did not comply with the section cited above in three out of five staff records reviewed did not have sufficient annual training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2023
	Plan of Correction
1 2 3 4	Licensee will write a statement of commitment commiting to providing staff with required annual training. Licensee will send statement by 5/23/23.

Type B

Section Cited

HSC

1569.625(c)(8)

Other Provisions

(c) The training shall include, but not be limited to, all of the following: (8) The special needs of persons with Alzheimer’s disease and dementia, including nonpharmacologic, person-centered approaches to dementia care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews, the licensee did not comply with the section cited above in three out of five staff records reviewed did not have sufficient annual training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2023
	Plan of Correction
1 2 3 4	Licensee will write a statement of commitment commiting to providing staff with required annual training. Licensee will send statement by 5/23/23.

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: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/16/2023 02:59 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: INGLESIDE BY THE LAKE	FACILITY NUMBER: 405850247
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.696(a)

Other Provisions

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews, the licensee did not comply with the section cited above in three out of five staff records reviewed did not have sufficient annual training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2023
	Plan of Correction
1 2 3 4	Licensee will write a statement of commitment commiting to providing staff with required annual training. Licensee will send statement by 5/23/23.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews, the licensee did not comply with the section cited above in two out of four emergency disaster drills were documented which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2023
	Plan of Correction
1 2 3 4	Licensee will write a statement of commitment commiting to conducting quarterly emergency disaster drills. Licensee will send statement by 5/23/23.

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: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/16/2023 02:59 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: INGLESIDE BY THE LAKE	FACILITY NUMBER: 405850247
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(3)(A)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: (A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living; This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews, the licensee did not comply with the section cited above in three out of five staff records reviewed did not have sufficient annual training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2023
	Plan of Correction
1 2 3 4	Licensee will write a statement of commitment commiting to providing staff with required annual training. Licensee will send statement by 5/23/23.

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: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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: 05/16/2023

NARRATIVE

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Kitchen was sufficiently stocked with two-day perishable and seven-day non-perishables. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. The refrigerator and freezer were in compliance with temperatures.
Resident rooms have beds with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and enough lighting for each resident. There is enough linen available to change weekly or more, if need.
Bathrooms were checked for cleanliness and proper operation. The hot water temperature measured between 112 F and 119 F degrees in resident bathrooms. Residents have a sufficient amount of supplies for personal hygiene. Soap, paper towels and toilet paper are provided by the Licensee. Grab bars are secured in toilet and shower areas. Showers have non-slip bottoms or mats.
Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for current Medical Assessments with TB results, Current Appraisal Needs and Service plans, and signed Admission Agreements. Planned activities are offered to residents in care. Resident files reviewed were in compliance.
Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations, Health screening with TB results, current First Aid/CPR, and Administrator Certificate. Three out of five staff records reviewed indicate that there is insufficient documentation showing that staff met the minimum hours of required annual training. Deficiency cited.
Medications are in a centrally stored and locked room next to the kitchen, including over-the-counter medicines. Medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the residents’ doctor. Proper medication dispensing instructions are followed. The first aid kit has all proper items and is current.

Exit interview conducted, deficiencies cited, and the report and appeal rights given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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