425801219-3-8-2021-29-AS-JROS-BYWQU5-20210308112811

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801219
Report Date: 03/03/2021
Date Signed: 03/08/2021 11:28:37 AM

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:	CARPINTERIA SENIOR LODGE		FACILITY NUMBER:	425801219
ADMINISTRATOR:	JOY KINGSTON		FACILITY TYPE:	740
ADDRESS:	4650 7TH STREET		TELEPHONE:	(805) 566-5364
CITY:	CARPINTERIA	STATE: CA	ZIP CODE:	93013
CAPACITY:	6	CENSUS: 0	DATE:	03/03/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:13 AM
MET WITH:	Joy Kingston		TIME COMPLETED:	10:48 AM

NARRATIVE

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Licensing Program Analyst (LPA) JoAnn Rosales conducted a case management visit virtually with Administrator Joy Kingston due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures.

On 1/29/2021 LPA spoke with the Administrator who stated that they were planning on closing the facility. This was the first notification from the Administrator that Community Care Licensing (CCL) received regarding the facility closure. On 1/29/2021 LPA received a fax from the Administrator with copies of eviction notices dated 1/21/2021 for the 3 residents of the facility. Upon receipt of the eviction notices on 1/29/21 LPA observed that the the eviction notices did not include the following: resident #1 (R1) did not receive a 60 day notice of eviction, all 3 residents did not have the following: a copy of the residents service plan, relocation evaluation, list of referral agencies, right of the residents or the resident's legal representative to contact the department to investigate the reasons given for the eviction pursuant to Section 1569.35, the contact information for the local long-term care ombudsman, including address and telephone number and Administrator did not submit the written reports of the evictions to CCL within five days.

During today’s visit, LPA toured the facility and observed that there were no residents in care residing at the facility. Administrator stated that they will mail the facility license to Community Care Licensing Woodland Hills office.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

A telephonic exit interview was conducted with the Administrator, and a hard copy was provided via email for signature

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021

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: CARPINTERIA SENIOR LODGE	FACILITY NUMBER: 425801219
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/05/2021 Section Cited	1 2 3 4 5 6 7	1569.682(a)(2) Transfer of resident upon forfeiture of license or change in use of facility; duties of licensee; closure plan; duty of department upon licensee’s failure to comply; civil penalties.(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility... This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on record review, the licensee did not comply with the section cited above as the eviction letters did include all the requirements of H&S 1569.682 which poses a potential personal rights risk persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021

LIC809 (FAS) - (06/04)

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