421703870-4-20-2023-29-AS-JOLN-CR3TXW-20230420150750

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 421703870
Report Date: 04/20/2023
Date Signed: 04/20/2023 03:08:23 PM

Document Has Been Signed on 04/20/2023 03:08 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MARSH'S BOARD & CARE		FACILITY NUMBER:	421703870
ADMINISTRATOR:	MARSH,SUSAN 98		FACILITY TYPE:	740
ADDRESS:	233 ALDEBARAN AVENUE		TELEPHONE:	(805) 733-2231
CITY:	LOMPOC	STATE: CA	ZIP CODE:	93436
CAPACITY:	5	CENSUS: 2	DATE:	04/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Sue Marsh, Administrator/Licensee		TIME COMPLETED:	03:30 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) Jenny Olson arrived unannounced to conduct a one year required annual. LPA was accompanied by Tracy Jackson, Quality Assurance Specialist (QAS) for Tri-Counties Regional Center. LPA and QAS met with Licensee/Administrator Sue Marsh and explained the reason for the visit.

LPA and QAS toured the physical plant areas to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The facility has a sufficient supply of non-perishable food items but needs a few more perishable items. Cleaning supplies and disinfectants are stored in the laundry room, inaccessible to clients. Knives are stored in a cabinet in the kitchen. Around 1:00 p.m., the hot water temperature measured in the kitchen at 116.2 degrees Fahrenheit.

Common areas: Living and dining room furniture were observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. At 11:15 a.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced 2/2/2023.

The backyard has a covered outdoor area equipped with furniture for client use. No bodies of water noted. The washer and dryer are in a room off the kitchen.

Restrooms: Two client restroom were clean and sanitary and in operating condition. The bathrooms were sufficiently stocked with soap and paper towels.

Bedrooms: There are two (2) client bedrooms, which were furnished with appropriate linens and required furniture. A linen closet was located outside of the rooms, which stocked extra linens and towels.

Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

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 11

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: MARSH'S BOARD & CARE	FACILITY NUMBER: 421703870
	VISIT DATE: 04/20/2023

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

Records: LPA reviewed client and staff records at 11:30 a.m. LPA reviewed two (2) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All files were complete but medical assessments should be updated.

LPA reviewed two (2) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. Administrator was missing their health screening from 1990.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 3 home. The last disaster drill was conducted on 4/7/2023.

Medications: Medications review began at 1:30 p.m.; medications are centrally stored and locked in a cabinet in the dining room. Medications are labeled and checked for expiration dates. The LPA advised the Administrator to ensure that all the necessary information is properly documented on the MAR.

Infection Control: The facility has an infection control plan The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocols needs to be improved.. The facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Exit interview conducted. A copy of the report was printed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC809 (FAS) - (06/04)

Page: 2 of 11