425801020-12-10-2024-29-AS-EMIR-DBU47H-20241210175111

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801020
Report Date: 12/10/2024
Date Signed: 12/10/2024 05:51:22 PM

Document Has Been Signed on 12/10/2024 05:51 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:	OPTIONS: ALVIN STREET		FACILITY NUMBER:	425801020
ADMINISTRATOR/ DIRECTOR:	FRAN L WALKER		FACILITY TYPE:	735
ADDRESS:	937 WEST ALVIN STREET		TELEPHONE:	(805) 922-6845
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY: 4		CENSUS: 4	DATE:	12/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Brian Carroll, Residential Manager		TIME VISIT/ INSPECTION COMPLETED:	06:00 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) Erika Miller arrived at 1:30 p.m. to conduct a 1-year required annual visit. LPA met with Brian Carroll, residential manager and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has at least 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). Physical Plant & Environment Safety: LPA toured resident rooms and observed that rooms were tidy and free of odor. The lighting and lamps are sufficient for the use of the facility and for resident comfort.Toilet, hand washing and bathing facilities are operational. The showers have slip resistant mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant and cleaning solutions are inaccessible to residents in care and locked in a cabinet in the laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. Resident manager advised that side gate will have a missing slat replaced immediately. The facility has telephone and internet service for resident use. The fire extinguisher was last charged and inspected on 7/8/24. The facility has smoke and carbon monoxide detectors that were tested and working properly. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

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: OPTIONS: ALVIN STREET	FACILITY NUMBER: 425801020
	VISIT DATE: 12/10/2024

NARRATIVE

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Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 6. The fire clearance is granted for 6 ambulatory residents. The facility currently has 4 ambulatory residents.

Staffing: The facility currently employs 8 full time staff, and 1 administrator. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, and Fingerprint clearance/Associations/exemptions. Administrator Certificate for Fran Walker expires on 7/24/26.

Personnel Records & Training: Staff have training completed for various subjects/topics and hours for 2024.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 4 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, (TCRC IPP) Emergency and ID forms, all forms were legible, and records are kept confidential.

Food Service:. 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. Cleaning solutions and equipment are stored separately from food supplies.

Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR) and Medical Administration Record (MAR). LPA reviewed residents’ medications, no labels were altered, no medications were expired, and all medications were kept in their original containers.

Disaster Preparedness: The current emergency disaster forms were posted. The facility last conducted a fire disaster drill on 11/19/24. Emergency exits and telephone numbers are posted. A set of keys is available for staff on all shifts to access full facility in an emergency.
Exit interview conducted and copy of report printed for residential manager.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC809 (FAS) - (06/04)

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