425800926-5-8-2024-29-AS-MRAN-D53TB2-20240508143426

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800926
Report Date: 05/08/2024
Date Signed: 05/08/2024 02:34:45 PM

Document Has Been Signed on 05/08/2024 02:34 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	TINA'S GENTLE CARE HOMES I		FACILITY NUMBER:	425800926
ADMINISTRATOR:	ROBERTS, VALENTINA		FACILITY TYPE:	740
ADDRESS:	1625 ROWLAND DR.		TELEPHONE:	(805) 925-0748
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	6	CENSUS: 4	DATE:	05/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Valentina Roberts		TIME COMPLETED:	02:50 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) De Leon and Rankin arrived at 09:30 am to conduct a 1 year annual visit to the facility above. LPA met with Valentina Roberts and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility Infection Control Plan on file. The facility has a sign in and out clipboard for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Some trash cans and waste baskets have tight fitting covers, administrator agreed to replace those without lids. Physical Plant & Environment Safety: The facility is a 4 bedroom and 2 bathroom, with one staff room in the garage. The facility is occupying 4 residents and employs 9 staff of which one is the Administrator and one is a live in staff. The facility is clean, safe and sanitary. LPA's were authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. Carbon Monoxide was tested and working properly. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TINA'S GENTLE CARE HOMES I	FACILITY NUMBER: 425800926
	VISIT DATE: 05/08/2024

NARRATIVE

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The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with furniture and plenty of shade. The facility has telephone and internet service for resident use.

Operational Requirements: The facility has a current plan of operation on file. The Facility is operating in compliance with the granted fire clearance based on the facility sketch. LPA received a new facility sketch and county permit; licensee is submitting for an updated fire clearance. The facility has current liability insurance and expires on 09/21/24. The facility is approved for a capacity of 6 bedridden and approved for hospice waiver of 4.

Staffing: The facility employes 8 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 3 staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and an Administrator Certificate expires on 8/19/24. All files were kept up to date with all requirements being met.

Personnel Records & Training: The facility keeps confidential files. LPA reviewed 3 staff training records for Annual Training Requirements of 20 plus hours. Trainer met the requirements to train staff.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four files were reviewed for signed Admission Agreements, Medical Assessments, LIC 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. The facility does not handle cash resources.
Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TINA'S GENTLE CARE HOMES I	FACILITY NUMBER: 425800926
	VISIT DATE: 05/08/2024

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Incidental Medical & Dental: The facility has a medication cabinet in the kitchen that is kept locked. Facility provides or assist in providing transportation to medical and dental appointments when needed. The medications records were reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected medication cabinet for all prescription and PRN medications with Doctors orders. LPA reviewed all residents medications, no medications labels were altered, no expired medications, and medications were stored in original containers.

Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers was charged. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or inaccessible to residents in care. The facility does not have delayed egress. The facility does not currently have residents with oxygen. The facility has 2 residents currently on Home Health services. Home Health services records are kept on file. The facility gate is self-latching and has self-closing equipment on one side. The backyard is completely fenced, administrator will be doing minor fence repairs. The facility has exiting door alarms, which were working on LPA's visit.

LPA conducted interviews with 2 staff and 1 resident.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

LIC809 (FAS) - (06/04)

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