421700369-8-9-2024-29-AS-EMIR-D7YV64-20240809160856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 421700369
Report Date: 08/09/2024
Date Signed: 08/09/2024 04:08:59 PM

Document Has Been Signed on 08/09/2024 04:08 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:	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: 160	DATE:	08/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Lori Kelley, Director of Peronsal Care		TIME COMPLETED:	04:30 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 9:45 a.m. on 4/15/24 to conduct a one-year annual visit to the facility above and at 2:45 p.m. on 8/9/2024. LPA met with Julie Driscoll, Social Services Director and Lori Kelley, Director of Personal Care 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 a capacity of 188 residents. Facility currently occupies 160 residents and employs 88 full time staff and one Administrator. The facility had a smoke and carbon monoxide detector that were tested are and working properly. The fire extinguishers were last charged and inspected on 4/19/24. 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. 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. The facility has sufficient space inside and outside for activities and visiting. 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 that expire on 3/1/2025. The facility is approved for a capacity of 188. The fire clearance is granted for 148 non-ambulatory and 40 ambulatory residents. Facility is approved for delayed egress and secured perimeter. Hospice is approved for eight. 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: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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 2

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: ATTERDAG VILLAGE OF SOLVANG	FACILITY NUMBER: 421700369
	VISIT DATE: 08/09/2024

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
26
27
28
29
30
31
32

Staffing: The facility currently employes 88 full time and one Administrator. Ten staff files were reviewed. Current Administrator Certificate expires August 25, 2024.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours.

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 ten 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. Cleaning solutions and equipment are stored separately from food supplies.

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 does not currently have residents receiving Home Health services. Exit door alarms are working.

Exit interview conducted, copy of report provided to administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC809 (FAS) - (06/04)

Page: 1 of 1

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: ATTERDAG VILLAGE OF SOLVANG	FACILITY NUMBER: 421700369
	VISIT DATE: 08/09/2024

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
26
27
28
29
30
31
32

Staffing: The facility currently employes 88 full time staff and one Administrator. Ten staff files were reviewed. Current Administrator Certificate expires August 25, 2024.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours.

Exit interview conducted, copy of report provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2