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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850375
Report Date: 09/07/2023
Date Signed: 09/07/2023 05:02:26 PM


Document Has Been Signed on 09/07/2023 05:02 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:PACIFIC HEIGHTS RESIDENTIAL HOME LLCFACILITY NUMBER:
405850375
ADMINISTRATOR:CRADDUCK, CHERLYNFACILITY TYPE:
740
ADDRESS:781 LILAC DRIVETELEPHONE:
(805) 534-1589
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY:5CENSUS: 5DATE:
09/07/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cherlyn Cradduck, Administrator/LicenseeTIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) De Leon conducted an announced Pre-Licensing visit to the facility above. This is a change of ownership application for a current facility with residents in care. LPA met with Licensee/Administrator Cherlyn Cradduck and explained the purpose of todays visit.

The following was inspected and noted during the Pre-Licensing visit:

Infection Control: The facility has a current Infection Control Plan on file. The facility has a sign in and out binder 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 when and if needed. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and waste baskets have tight fitting covers.

Operational Requirements: The facility has a current plan of operation, admission agreement and infection control plan submitted with the change of ownership application. The facility has current liability insurance expiring on 04/07/2024. The facility has applied for a capacity of 5 with 4 Non-Ambulatory of which 1 may be bedridden in bedroom #2. The fire clearance was granted for 5 with 4 non-ambulatory and 1 bedridden but does not specify which room the bedridden is granted for. LPA will contact the fire inspector to get the fire clearance updated to specify which is the approved bedridden bedroom. The facility has theft and loss policy as well as investigation procedures posted in front entry.


Continued 809-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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: PACIFIC HEIGHTS RESIDENTIAL HOME LLC
FACILITY NUMBER: 405850375
VISIT DATE: 09/07/2023
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Physical Plant & Environmental Safety: The facility has 3 resident bedrooms and 2 resident bathroom currently occupying 5 residents and employs 5 full time staff with back up staffing if needed. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. Carbon Monoxide detector was tested and working properly. 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. Residents are provided privacy and confidentiality. The pathways inside and outside are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents and locked under the kitchen sink and in the locked garage cupboards. 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. Telephone and internet service is provided for residents in care. The facility has a working washer and dryer with all needed supplies for operation. The water temperature was checked at the kitchen sink and measured at 120.0 degrees Fahrenheit. The facility has beds, mattresses, furniture and bedding in good repair. Fireplace is screened. Windows and screens are it good repair. Hygiene items such as soap and toilet paper are supplied by the facility for residents in care. Night-lights are maintained in the hallways for the safety of residents in care. There are no bodies of water on the premises. The facility does not allow fire arms or ammunition to be kept at the facility.
Staffing: The facility staff will ensure the facility is kept clean, safe, sanitary and good repair. Administrator certificate is valid and expires 03/16/2025.
Personnel Records & Training: The facility will maintain confidential files for the Licensee, Administrator and employees. All criminal records for clearance or exemption will be kept in those files. Files are kept at the facility and kept locked in hall closet for confidentially. Disaster Drills are conducted quarterly and records of drills kept on file. Staff will meet all initial or annual training requirements and records will be kept on file.
Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Pre-Admission appraisals are conducted on perspective residents before accepting them into care and kept on file. Resident files will have will have 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 maintained in files. The Licensee will post a sign that the approved admission agreement with modifications and attachments is on file and can be reviewed at any time. A current register of residents will be on file at the facility. The Facility will submit incident reports to the department when required. Continued 809-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
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: PACIFIC HEIGHTS RESIDENTIAL HOME LLC
FACILITY NUMBER: 405850375
VISIT DATE: 09/07/2023
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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. Resident Council have a space for posting in the facility when and if required. CCL Complaint poster and LTCO poster were posted in the entry way of facility. The visitation policy and hours are posted at front entry. Internet is provided to residents in care with confidentiality and privacy.
Planned Activities: A comfortable space is provided inside and outside for activities and facility maintains supplies for activities program. The facility provides a furnished living area for relaxation and entertaining as well as a furnished courtyard with shade for resident use.
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. 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 trained for personal hygiene and food sanitation practices. All equipment, supplies and dishes are kept clean and maintained in good repair.
Incidental Medical & Dental Services: Facility provides transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). Medications for all resident in care are centrally stored and locked in hallway medication closet. The facility has a first aid kit with all required contents on premises. Arrangements will be made if a resident illness requires care and separation from others.
Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. 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. Facility has emergency food and water supply, flash lights with batteries, and a cooler with ice packs for medications. The facility has two evacuation locations and a place available for a back up generator if sheltering in place.
Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have any residents currently using oxygen and if the facility does accept a resident in care signs will be posted for "No Smoking-Oxygen is use", on the facility front door and the bedroom door of the resident. The facility does not have any delayed egress. The facility has two self latching, self closing gates at each side of the facility, all exiting doors are alarmed. There are no bodies of water on the premises.
Exit interview conducted, Comp III completed with Licensee and copy of report printed for Licensee/Administrator
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC809 (FAS) - (06/04)
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