425800777-10-20-2022-29-AS-KKOS-CKDKSM-20221020080946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800777
Report Date: 10/19/2022
Date Signed: 10/20/2022 08:11:06 AM

Document Has Been Signed on 10/20/2022 08:11 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:	HERITAGE HOUSE-AN ASSISTED LIVING COMMUNITY		FACILITY NUMBER:	425800777
ADMINISTRATOR:	ROSEMARIE L. HARRIS		FACILITY TYPE:	740
ADDRESS:	5200 HOLLISTER AVE.		TELEPHONE:	(805) 967-2661
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93111
CAPACITY:	68	CENSUS: 58	DATE:	10/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Rosemarie Harris, Administrator		TIME COMPLETED:	05:00 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) Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection and Annual visit to the above-named facility. LPA arrived at 1:50 PM and was greeted by Diane Gomersall, Front Desk Receptionist. Administrator Harris was present during the inspection. At the time of arrival, there were 58 residents in care and approximately 28 staff on duty. Alejandra Nunez, Assistant Administrator participated in the inspection. A Mitigation Plan has been submitted to CCLD. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a Dementia diagnosis and a Hospice Waiver for 25 residents. Currently, there are 17 residents on hospice. Entrance interview conducted: A tour of the physical environment and accommodations were assessed. The following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the two-story facility for fire safety, personal accommodations and food service. The facility maintains a comfortable room temperature. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. There are 16 fire extinguishers on the premises last serviced on 10/8/2021. There is a total of 78 dual carbon monoxide detectors/smoke alarms throughout the facility. The local fire department is alerted when/if the smoke alarms/carbon monoxide detectors are activated. Fire drills are conducted approximately twice each year. Residents participate at will in activities such as (but not limited to) music and live entertainment, spiritual program activities, Bible study, outings with family members, games, art activities, painting activities, storytelling, word games, travel shows, tri-shaw rides, van rides, and picnics to local parks and attractions. Additionally, the facility participates in the state-based Vitality program through the local community college. Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

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 3

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: HERITAGE HOUSE-AN ASSISTED LIVING COMMUNITY	FACILITY NUMBER: 425800777
	VISIT DATE: 10/19/2022

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

Snacks and beverages are available for residents in care upon request. LPA observed the kitchen area and dining areas to be clean. Cleaning agents and the toxic chemicals are kept in locked supply rooms throughout the facility.
The facility consists of four neighborhoods each conducive to the level of care required for the residents. All bedrooms have sufficient lighting, nightstands, beds, and bed furnishings. A locked medication cart is designated for each neighborhood in the Wellness Clinic. First aid supplies are also kept in the Wellness Clinic.
Neighborhood #4 is a neighborhood for residents who require a higher level of care. The facility maintains a higher staff ratio in Neighborhood #4 to meet the needs of the residents.
Throughout the neighborhoods, there are dining rooms, libraries, beauty salon, social seating areas, outdoor patios, and paved walkways conducive for leisure walks throughout the facility.
The physical environment was checked for cleanliness and condition. The facility was seen to be in good repair inside and outside.
First aid kit and additional first aid supplies are kept in a locked centrally stored cabinet in the Wellness Clinic, the Personal Care area, and in the kitchen.
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. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of COVID-19. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals.
PPE supplies will be located immediately 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/isolation resident room.
The facility has proper cleaning and disinfectant sprays. 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 an infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Staff who have a respiratory illness are requested to stay home and not report to work.
Please continue to 809-C, Pg 3.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: HERITAGE HOUSE-AN ASSISTED LIVING COMMUNITY	FACILITY NUMBER: 425800777
	VISIT DATE: 10/19/2022

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

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 and resident records are kept in the locked staff office. Facility observes 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 Certificate is valid.

Exit interview conducted. No citations issued. A copy of this report has been issued via email.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3