421700369-3-18-2023-29-AS-RDLN-CPYVZN-20230316165300

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 421700369
Report Date: 03/16/2023
Date Signed: 03/18/2023 09:28:23 AM

Document Has Been Signed on 03/18/2023 09:28 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:	ATTERDAG VILLAGE OF SOLVANG		FACILITY NUMBER:	421700369
ADMINISTRATOR:	CHRIS PARKER		FACILITY TYPE:	741
ADDRESS:	636 N ATTERDAG ROAD		TELEPHONE:	(805) 688-3263
CITY:	SOLVANG	STATE: CA	ZIP CODE:	93463
CAPACITY:	188	CENSUS: 31	DATE:	03/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Chris Parker, Administrator		TIME COMPLETED:	05:00 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’s (LPA’s) De Leon, Chavez and Phillips arrived at 9:07 am and made an unannounced 1-year required annual visit to the facility above. LPA’s met with Chris Parker, Administrator and explained the purpose of the visit. LPA’s requested a staff roster, a resident roster, emergency and disaster plan, documentation of quarterly emergency drills. LPA’s provided administrator the entrance checklist and asked for a physical plant tour. A tour of the physical plant was assessed, and the following was noted: LPA's observed the license posted, personal rights, LTCO poster, Bill of Rights and Right to Residential Council as well as covid sign for infection control and CCL complaint poster. The facility has an assisted living building and a memory care building on the CCRC Campus. The assisted living has bedrooms, bathrooms, common area rest-rooms, kitchen, dining rooms, library, activity room, laundry room, medication rooms, locked housekeeping closets, courtyard and is currently occupying 31 Residents total with 13 in assisted living,18 in memory care and 90 staff. Physical plant was checked 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 working telephones for resident use. The dual smoke/carbon monoxide detectors are hard wired with sprinkler system and the annual fire inspection was cleared. Fire extinguishers were last inspected 04/19/2022 and all charged in the green. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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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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: ATTERDAG VILLAGE OF SOLVANG	FACILITY NUMBER: 421700369
	VISIT DATE: 03/16/2023

NARRATIVE

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Living and dining rooms furniture were also checked for functionality and condition. The living rooms are clean, safe and sanitary along with the dining rooms.
The courtyard of the facility has outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. There is a small water fountain that is empty outside of the assisted living building. There is plenty of outdoor lighting available for the safety of the residents.
Continued on 809C.
The kitchen area 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. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers.
The 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. Residents arranged the rooms the way they want them. There is enough linen available to change weekly or more if need.
The housekeeping closets are locked, carts are stored with cleaning products and solutions.
The bathrooms were checked for cleanliness and proper operation. The hot water temperature measured at 112.9 F in common room/bathroom #3, room #5 bathroom at 114.1 F. Towels and washcloths are not shared. Residents have a sufficient amount of supplies for personal hygiene. Soap, Toilet paper and paper towels are provided by the Licensee. Grab bars are secured in toilet and shower areas. Showers have non-slip bottoms or strips.
Resident records were reviewed for requirements and legibility: LPA Phillips reviewed 5 resident’s 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.
Staff records were checked for expired or missing certificates and clearances:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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: ATTERDAG VILLAGE OF SOLVANG	FACILITY NUMBER: 421700369
	VISIT DATE: 03/16/2023

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LPA Chavez conducted a file review of 5 staff for criminal record clearances/associations, Health screening with TB results, current First Aid/CPR, caregivers/Med-tech annual training has been completed and Administrator Certificate has been renewed and is currently pending with CCL for issuance, back up Administrator certificate expires on 08/10/2024.
Medications are in a centrally stored and locked medication rooms, 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 instruction are followed. First Aid Kit has all proper items and is current.

Infection Control best practices were discussed with Administrator for proper donning, doffing, and lidded trash cans.

Exit interview conducted, Technical violations issued and copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC809 (FAS) - (06/04)

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