421700411-9-20-2022-29-AS-JOLN-CJG46C-20220920184920

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 421700411
Report Date: 09/20/2022
Date Signed: 09/20/2022 06:50:19 PM

Document Has Been Signed on 09/20/2022 06:50 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:	VALLE VERDE		FACILITY NUMBER:	421700411
ADMINISTRATOR:	SUSAN E PONCE		FACILITY TYPE:	741
ADDRESS:	900 CALLE DE LOS AMIGOS		TELEPHONE:	(805) 883-4193
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93105
CAPACITY:	547	CENSUS: 369	DATE:	09/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Susan Ponce, Administrator		TIME COMPLETED:	05:45 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 Analysts (LPA's) Kontilis, Olson, and Cortez conducted an unannounced infection control annual inspection. LPA's were greeted by Concierge around 11:18 and Administrator around 11:30 AM. Currently, there are 369 residents living within the community. There are 327 residents residing in Residential Living, 26 residents residing in Quail Lodge, the Assisted Living area of the community, and 16 residents residing in The Grove, the memory care unit of the community. LPA's reviewed staff roster from 11:40 AM to 1:10 pm LPA's Olson and Cortez took a physical plant tour of the facility with Assisted Living and Memory support Manager from 1:30 to 3pm. This facility consists of Independent Living section, Quail Lodge Resident, and The Grove Memory Care. Medications are kept in a locked medication room. Main kitchen, dining rooms, various activity rooms were toured. The facility has a swimming pool. Swimming pool is secured. The kitchen was inspected for cleanliness and sanitary condition. The facility has multiple areas spaced to accommodate as much space as possible for social distancing. The staff screen residents for symptoms and temperature at least once a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature. Signs are posted on the front door, entry area regarding Covid-19. Continued on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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: VALLE VERDE	FACILITY NUMBER: 421700411
	VISIT DATE: 09/20/2022

NARRATIVE

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Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility have areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed.

Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility has plans for delivering medications and meals to any quarantined/isolation resident rooms. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies.Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in locked offices. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. Administrator Certificates are valid. Fire extinguishers were charged and inspected annually. The facility has hardwired smoke detectors thorough the facility.

At approximately 11:40 am, LPAs reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined there are 3 staff members currently working in the facility and have not been associated to the facility prior to their employment. Additionally, one staff member has not received a criminal background and/or fingerprint clearance.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D),

Exit interview conducted. Report, Civil penalties and Appeal Rights issued via email.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/30/2022 04:56 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/30/2022 04:47 PM

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: VALLE VERDE	FACILITY NUMBER: 421700411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This is an ammended report due to a computer error Based on record review and interview, the licensee did not comply with the section cited above as one (1) facility staff did not receive a 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: 09/21/2022
	Plan of Correction
1 2 3 4	Licensee agrees that staff members will not work at this facility without receiving a criminal background/fingerprint clearance and will be taken off the schedule until then. Civil Penalty assessed in the amount of $500.

Type A

Section Cited

CCR

87355(e)(2)

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: (2) 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 as three (3) facility staff were not associated to work in the facility prior to working in the facility which poses an immediate health and safety risk to residents in care.
	POC Due Date: 09/21/2022
	Plan of Correction
1 2 3 4	Licensee agrees that staff members will not work at this facility without an appropriate transfer and will be taken off the schedule until associated. Civil Penalty assessed in the amount of $1,500.

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: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC809 (FAS) - (06/04)

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