425800675-7-1-2022-29-AS-JOLN-CFWPFB-20220701111627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800675
Report Date: 07/01/2022
Date Signed: 07/01/2022 11:16:55 AM

Document Has Been Signed on 07/01/2022 11:16 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:	MYDOR'S OPEN GUEST HOME, INC. II		FACILITY NUMBER:	425800675
ADMINISTRATOR:	AMELITA ANTONIO		FACILITY TYPE:	740
ADDRESS:	1011 NORTH COLLEGE DRIVE		TELEPHONE:	(805) 928-8218
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	6	CENSUS: 6	DATE:	07/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Administrators Juanito Pasion and Antenor Porlucas		TIME COMPLETED:	11:20 AM

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) Olson conducted an on-site 1 year infection control annual visit to the facility above on 07/1/2022 at 10:45 AM. LPA met with Administrator Juanito Pasion, and Antenor Porlucas and explained the purpose of the visit. LPA took a physical plant tour of the inside and outside of the facility with Staff. The facility has an entry point at the front door where everyone entering completes sign-in, symptoms screening and temperature check for all staff and visitors wanting to come into the facility. All documentation is kept in a file. The staff screen residents for symptoms and temperature 1x 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 and throughout the facility regarding Covid-19. 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 has 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. Residents and Responsible Parties are notified by facility when required. Residents rights are not being violated. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Emergency Disaster plan is updated with telephone numbers. Administrator Juanito Pasion is in charge of infection control and provides training and education to staff, residents and visitors. 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: 07/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022

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: MYDOR'S OPEN GUEST HOME, INC. II	FACILITY NUMBER: 425800675
	VISIT DATE: 07/01/2022

NARRATIVE

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If any suspected or confirmed cases of Covid-19 are found in the facility a staff will use full PPE supplies that will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined or isolated resident room. The facility has proper cleaning and disinfectant policies. Facility Administrators have 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. 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 and resident records are kept in locked cabinet. 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. Administrators Certificates are valid. Fire extinguishers are charged and inspected annually. Smoke alarms and Carbon monoxide detectors are present.

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

Exit interview completed and copy of report 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: 07/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022

LIC809 (FAS) - (06/04)

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