425801823-10-20-2022-29-AS-JOLN-CKDUWU-20221020155718

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801823
Report Date: 10/20/2022
Date Signed: 10/20/2022 03:57:50 PM

Document Has Been Signed on 10/20/2022 03:57 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AMALIA'S RESIDENCE II		FACILITY NUMBER:	425801823
ADMINISTRATOR:	DEXTER PRICE		FACILITY TYPE:	740
ADDRESS:	1206 KENSINGTON AVENUE		TELEPHONE:	(805) 287-9630
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY: 6		CENSUS: 6	DATE:	10/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Dexter Price, Administrator		TIME COMPLETED:	11:50 AM

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Licensing Program Analyst (LPA) Olson conducted an on-site 1-year infection control annual visit to the facility above on 10/20/2022 around 10:10AM. LPA met with Dexter Price, Administrator/Licensee and explained the purpose of the visit.

LPA took a physical plant tour of the facility with Staff. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening on all staff and visitors wanting to come into the facility. The entry station has hand sanitizer along with a thermometer. The staff screen residents for symptoms and temperature at least once a day and documentation is kept on file. Increased monitoring is conducted if any change of condition is noted or any residents are showing any signs, symptoms, or a temperature. Signs are posted on the front door, entry area regarding Covid-19. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility has areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, residents, and visitors are informed of the facilities infection control policies. New residents and staff will be tested, and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed.

The Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Facility has submitted an Infection Control Plan and Emergency Infection Control plan.

Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

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: AMALIA'S RESIDENCE II	FACILITY NUMBER: 425801823
	VISIT DATE: 10/20/2022

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Staff will use full PPE with N95 masks and face shields when around with any pending or confirmed cases of Covid-19. Facility has plans in place for residents in isolation. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30-day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident rooms. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission, and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Residents’ medication is delivered in 30-day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in a locked closet. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. Administrator Certificate is valid. Smoke and Carbon Monoxide Detectors present and working.

All infection control protocols are implemented and are being followed.

At approximately 11:15 AM, LPAs reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined all staff have been associated to the facility and received a criminal background and/or fingerprint clearance prior to their employment.

Exit interview conducted. Report issued via email to administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC809 (FAS) - (06/04)

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