405850254-5-24-2022-29-AS-DCHZ-CEQVPK-20220524163653

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850254
Report Date: 05/24/2022
Date Signed: 05/24/2022 04:38:51 PM

Document Has Been Signed on 05/24/2022 04:38 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 PARK		FACILITY NUMBER:	405850254
ADMINISTRATOR:	ALLAN, BRETT		FACILITY TYPE:	740
ADDRESS:	9220 MOUNTAIN VIEW DRIVE		TELEPHONE:	(805) 460-7040
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	15	CENSUS: 10	DATE:	05/24/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Brett Allan, Applicant, and Zolton Soo, Applicant		TIME COMPLETED:	04:45 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 conducted a pre-licensing visit to the above noted facility. The LPA met with applicant and administrator, Brett Allan, and back-up 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 one story. At 2:00 pm, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for zero (0) non-ambulatory residents; zero (0) ambulatory residents; and, fifteen (15) bedridden residents. The facility has eight (8) private resident bedrooms and two offices in building 9222 which will be transformed into two (2) resident bedrooms per applicant. Rooms #1, 5, and 6 are shared room(s), 2 offices will be made into double-occupancy resident rooms, Rooms #2, 3, 4, 7, 8 are single-resident rooms. All resident rooms have direct exits to the outside. The facility is equipped with sprinklers in all rooms. 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 are no staff rooms – awake night staff only. All rooms were free of odors. All window screens were clean and maintained in good repair. There are three (3) bathrooms in the hallway, three (3) quarter bathrooms in Rooms #1, 2, and 3, and one (1) bathroom in the offices. Bathrooms #2 and 7 are designated as a staff bathrooms The resident bathrooms have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen. The hot water temperature was measured as follows: bathrooms #1 and 2 = 114.9F, bathrooms #3 and 4 = 116.4F, bathroom #5 = 115F, bathroom #6 = 107.7 and the kitchen = 108F, which falls within the allowable range of 105F to 120F. Bathroom #7 is used only by staff.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

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: INGLESIDE PARK	FACILITY NUMBER: 405850254
	VISIT DATE: 05/24/2022

NARRATIVE

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Resident and staff records are stored in a locked filing cabinet which is currently located in the dining room. Medications are centrally stored in the medication room near 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 cabinet in the kitchen.

Kitchen knives are stored in a locked cabinet in the kitchen. Stove burners are rendered inaccessible to the residents by removing them when not in use. 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 kitchen trash can has a lid, however, it is not a tight fitting lid. Applicant will purchase a tight-fitting lid and replace it with the current kitchen trash can. Kitchen, laundry and house cleaning supplies are stored in the locked medicine room. No flies or other vermin were observed.

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. 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 had emergency lighting on the ceiling in the hallways. 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. There is a pull station at the front entry of the house. The combination smoke detectors and carbon monoxide detectors were tested and functioned properly during the time of visit. There are three (3) fire extinguishers throughout the house and offices. They are fully charged and do not exceed the expiration date. The laundry room is located in the hall near Bedroom #4. The supply of extra bed and bath linens is adequate.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

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 PARK	FACILITY NUMBER: 405850254
	VISIT DATE: 05/24/2022

NARRATIVE

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Personal hygiene items (shampoos, soaps) were adequate and are stored in the hallway cabinets and Training and Conference Room. Extra incontinence supplies are stored in the Training and Conference Room. There is a functioning telephone on the premises, phone number 805-460-7040. The emergency exiting plans/sketch are posted in both hallways near resident bedrooms and at the front entrance way. The emergency telephone numbers are posted in the front entrance way. Other required postings are posted at the front entrance way.

The exterior passageways were clean and clear of any obstructions. There is a half-covered patio area and shading from a large tree at the back of the house with tables and chairs where residents can sit. The entire property is fenced. The back and sides of the house are separated from the front yard by gates at the east and west side passageways. There is no driveway gate. There is a separate office building which applicant says will be refurbished into two resident rooms. There is an additional room called the Training and Conference Room on the map, which is used for storage. There are no any bodies of water on the premises at the present time.
There is no garage.

The following items must be corrected prior to licensure: a tight-fitting trash can must be added to the kitchen and the current trash can removed. Submit proof of corrections, along with a copy of this report, to LPA so that your application may be completed.

Exit interview conducted and copy of report emailed to administrators.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

LIC809 (FAS) - (06/04)

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