425800464-7-20-2022-29-AS-JOLN-CGHRLB-20220720130651

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800464
Report Date: 07/20/2022
Date Signed: 07/20/2022 01:08:08 PM

Document Has Been Signed on 07/20/2022 01:08 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:	VISTA DEL MONTE		FACILITY NUMBER:	425800464
ADMINISTRATOR:	DOUGLAS TUCKER		FACILITY TYPE:	741
ADDRESS:	3775 MODOC ROAD		TELEPHONE:	(805) 687-0793
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93105
CAPACITY:	266	CENSUS: 197	DATE:	07/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Douglas Tucker, Administrator		TIME COMPLETED:	01:15 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) Olson conducted an on-site 1 year infection control annual visit to the facility above on 07/20/2022 at 10:00 AM. LPA met with Administrator Douglas Tucker and explained the purpose of the visit. LPA took a physical plant tour of the facility with Administrator from 10:20am-11:30am. The facility has an entry point at the front entrance where everyone entering completes sign-in, symptom questionnaire and temperature screening on all staff and visitors wanting to come into the facility. All documentation is kept on file. The entry station has a hand washing station, hand sanitizer along with thermometers. The facility has multiple areas spaced to accommodate as much space as possible for social distancing. The facility has multiple courtyards and outdoor areas for resident use with shade. All equipment and PPE supplies are kept in storage closets. Medications are kept in a locked medication room. 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 throughout the campus regarding Covid-19 and infection control. 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. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

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: VISTA DEL MONTE	FACILITY NUMBER: 425800464
	VISIT DATE: 07/20/2022

NARRATIVE

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Ali Reynoso, Director of Heath Services is in charge of infection control and provides training and education to staff, residents and visitors. If any suspected or confirmed cases of Covid-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals and will not work with other negative individuals until cleared by Health Department to do so. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident isolation.

Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolated resident room. The facility has proper cleaning and disinfectant policies. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff records are kept in the Human Resource office and resident records are kept in the Wellness Center. 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. The facility has hardwired smoke and carbon monoxide detectors thorough the facility. Fire extinguishers were charged and last serviced on 10/14/2021 in San Rafael, Sierra Madre, Fernbrook Assisted Living, and Summer House Memory Care and inspected annually. LPA observed fire extinguishers in Los Padres, Santa Ynez, and the Administration Building were charged but last serviced on multiple dates in 2020 and 2021 including 10/29/2020 and 03/18/2021.

No other deficiencies were observed during the visit, all infection control protocols are implemented and being followed.

Exit interview completed, deficiencies cited on 9099-D, copy of report and appeal rights emailed to Administrator/Licensee.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/20/2022 01:08 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VISTA DEL MONTE	FACILITY NUMBER: 425800464
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87203

87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as multiple fire extinguishers were last serviced in 2020 and 2021 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/29/2022
	Plan of Correction
1 2 3 4	Administrator agreed to service fire extinguishers and submit proof to CCL by 7/29/2022

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: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC809 (FAS) - (06/04)

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