425801661-9-17-2024-29-AS-EMIR-D97TR4-20240917145655

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801661
Report Date: 09/17/2024
Date Signed: 09/17/2024 02:57:19 PM

Document Has Been Signed on 09/17/2024 02:57 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:	PEDFLOR'S RESIDENTIAL CARE II		FACILITY NUMBER:	425801661
ADMINISTRATOR:	AUREA D. ALEJANDRO		FACILITY TYPE:	740
ADDRESS:	1315 E. ALVIN AVENUE		TELEPHONE:	(805) 349-7563
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	6	CENSUS: 3	DATE:	09/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Aurea Alejandro, Administrator		TIME COMPLETED:	03:30 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) Miller arrived at 11:00 am and made an unannounced 1-year required annual visit to the facility above. LPA’s met with Aurea Alejandro, Administrator 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 a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants sprays and cleaners. 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). Physical Plant & Environment Safety: The fire extinguisher was last charged and inspected on 2/12/24. The facility had 3 resident bedrooms and 2 bathrooms currently occupying 3 residents. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors that were tested. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. LPA observed disinfectant and cleaning solutions kept under the kitchen sink were left unlocked. LPA observed that Medication Storage cabinet was left unlocked. LPA observed that sharps drawer containing knives was left unlocked. Administrator immediately locked the disinfectants and cleaning solutions, the Medication cabinet and the sharps drawer. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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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Document Has Been Signed on 09/17/2024 02:57 PM - It Cannot Be Edited

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: PEDFLOR'S RESIDENTIAL CARE II	FACILITY NUMBER: 425801661
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as the medication cabinet was not locked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2024
	Plan of Correction
1 2 3 4	Submit a statment of understanding that medication storage will be locked by POC date to CCLD.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as the sharps drawer in kitchen was left unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2024
	Plan of Correction
1 2 3 4	Submit a statment of understanding that knives will be locked by POC date to CCLD.

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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/17/2024 02:57 PM - It Cannot Be Edited

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: PEDFLOR'S RESIDENTIAL CARE II	FACILITY NUMBER: 425801661
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as disinfectans, and cleaning solutions were left unlocked under the kitchen sink, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Submit a statement of understanding that disinfectants and cleaning solutions will be stored and inaccessible to clients by POC date to CCLD.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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: PEDFLOR'S RESIDENTIAL CARE II	FACILITY NUMBER: 425801661
	VISIT DATE: 09/17/2024

NARRATIVE

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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. The facility has telephone and internet service for resident use.

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 does not have current liability insurance. The facility is approved for a capacity of 6. The fire clearance is granted for 6 non-ambulatory of which 1 may be bedridden in room 2.

Staffing: The facility currently employs 4 employees and 1 administrator. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Administrator Certificate is pending processing.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training for various subjects/topics and hours for 2023 and 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 3 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible.

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.
Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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: PEDFLOR'S RESIDENTIAL CARE II	FACILITY NUMBER: 425801661
	VISIT DATE: 09/17/2024

NARRATIVE

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Incidental Medical Services: The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). 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 quarterly disaster drill 8/8/24. 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. The facility has 1 self-latching gates on one side of the home. The facility does not have delayed egress, locked doors or gates. Exit door alarms are working.

Exit interview conducted and copy of report, citations and appeal rights printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

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