425801376-5-10-2023-29-AS-BPHS-CRPU5Y-20230510151727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801376
Report Date: 05/10/2023
Date Signed: 05/10/2023 03:17:55 PM

Document Has Been Signed on 05/10/2023 03:17 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LE-NA' RESIDENTIAL #4		FACILITY NUMBER:	425801376
ADMINISTRATOR:	ESTELLA USHER		FACILITY TYPE:	735
ADDRESS:	151 PATTERSON ROAD		TELEPHONE:	(805) 934-2167
CITY:	ORCUTT	STATE: CA	ZIP CODE:	93455
CAPACITY: 4		CENSUS: 4	DATE:	05/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Estella Usher, Administrator		TIME COMPLETED:	03:00 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	On 05/10/2023 at 9:00am Licensing Program Analyst (LPA) Brian Phillips arrived at the facility to conduct a required annual 1-year site inspection. LPA met with Administrator Estella Usher and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is compliant with Title 22 Regulations. This is an Adult Residential Facility (ARF) with fire clearance for 4 ambulatory residents. Kitchen: The kitchen area was observed at 9:30am. The facility has a sufficient supply of non-perishable and perishable food items as well as utensils for all clients. Cleaning supplies and disinfectants are stored inaccessible to clients. Knives and sharp objects are stored in a locked cabinet. The stove and dishwasher are in operating condition. Food is stored properly in the refrigerator and pantry. Common areas: All furniture in the facility was observed to be in good condition. At 10:00am, smoke detectors and carbon monoxide detectors were tested and operational. The LPA observed required postings throughout the common space. The fire extinguishers were charged and serviced in January 2023. The washer and dryer are in the laundry room/area. Each resident has adequate supply of fresh linen located in 2 hall cabinets. Inside and outside passageways are free from obstruction. All rooms are maintained at a comfortable temperature and all window screens are in good repair and free of insects, dirt, and/or debris. Restrooms: The two client restrooms were clean, sanitary, and in operating condition with nonskid surfaces. The restrooms were sufficiently stocked with soap, required postings, and both restrooms had electric hand dryers. At 9:45am, the hot water temperature measured in the hallway restroom was within temperature regulations. Backyard: The backyard has furniture for client use with shade. The facility has a sun room for the residents. The exit from the facility is audio egress and the backyard gate is delayed egress. Contd. LIC809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LE-NA' RESIDENTIAL #4	FACILITY NUMBER: 425801376
	VISIT DATE: 05/10/2023

NARRATIVE

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LPA reviewed reviewed both resident files and staff member files. All files have the necessary documentation including physician reports, CNAS/IPP plans, admission agreements, emergency contact information, and consent forms. All staff files have health screenings, required training, First Aid/CPR certificates, and criminal record background check documentation.

LPA reviewed medications. Medications are stored in a locked cabinet. The cabinet has a labeled drawer for each resident including their picture and what time of day medication is required. There is a signed and dated order from physician for prescriptions and PRN medications. LPA observed the medication assessment record (MAR) and that the medication is given per physician's orders.

First Aid supplies/manual and earthquake supplies are accessible and maintained. Staff members participate in disaster drill training at least semi annually and have a current disaster/evacuation plan on file. The facility conducts monthly emergency drills for fire, evacuation, and earthquakes. All vehicles used to transport residents are maintained in safe operating condition.

LPA and Administrator reviewed all questions in all modules of the inspection care tool. All questions were in the affirmed yes or not applicable. There were no violations, technical or citations found during the review of the care tool and its modules. There were no citations, violations or technical issued as a result of the annual inspection.

Exit interview, report read, report signed and report provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC809 (FAS) - (06/04)

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