405850478-1-11-2024-29-AS-EMIR-CZE2NK-20240111163251

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850478
Report Date: 01/11/2024
Date Signed: 01/11/2024 04:32:56 PM

Document Has Been Signed on 01/11/2024 04:32 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	YOKAM'S RCFE # 1N		FACILITY NUMBER:	405850478
ADMINISTRATOR:	KAMTO, YOLANDE KONGUEP		FACILITY TYPE:	740
ADDRESS:	170 S. MESA RD		TELEPHONE:	(805) 619-7615
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY:	6	CENSUS: 3	DATE:	01/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Cheryll Estacio		TIME COMPLETED:	04:42 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) Miller arrived at 9:30 am to conduct a one year annual visit to the facility above. LPA met with Back-Up Administrator, Cheryll Estacio and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The facility has 3 resident bedrooms, 2 bathrooms and currently occupies 3 residents and employs five full time staff and one Administrator. LPA Miller was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors that were tested and working properly during visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats or textured bottoms. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked under sink. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance and expires on January 7, 2025. The facility is approved for a capacity of six. The fire clearance is granted for 6 non-Ambulatory of which four may be bedridden. Hospice is approved for four. Staffing: The facility currently employes five full time staff and one Administrator. Staff files were reviewed. LPA observed that one facility staff (S1) was not associated to work in the facility, but had fingerprint clearance prior to working in the facility. Current Administrator Certificate expires June 17, 2024. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: YOKAM'S RCFE # 1N	FACILITY NUMBER: 405850478
	VISIT DATE: 01/11/2024

NARRATIVE

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Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2023.
Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed five resident files for signed Admission Agreements.
Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables and plenty extra, 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 staff are observed for personal hygiene and food sanitation practices. Disaster Preparedness: The current emergency disaster forms were posted. 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.
Residents with Special Health Needs: The facility does accept dementia residents in care. The facility currently has residents receiving Home Health services. Exit door alarms are working.

LPA will return at a later date to continue the annual visit.
Exit interview conducted, copy of report, citation, civil penalty, and appeal rights were issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/11/2024 04:32 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: YOKAM'S RCFE # 1N	FACILITY NUMBER: 405850478
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above when one (1) facility staff was not associated to work in the facility but had fingerprint clearance and/or background check prior to working in the facility, which poses an immediate health and safety risk to residents in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Licensee shall ensure staff member will not work at this facility without an appropriate transfer. Civil Penalty assessed in the amount of $500.

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: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

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