425801936-7-13-2023-29-AS-JOLN-CTPVUH-20230713164446

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801936
Report Date: 07/13/2023
Date Signed: 07/13/2023 04:47:08 PM

Document Has Been Signed on 07/13/2023 04:47 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:	BAUER RESIDENTIAL SANTA MARIA 4		FACILITY NUMBER:	425801936
ADMINISTRATOR:	MOSHE DAVIS		FACILITY TYPE:	735
ADDRESS:	572 INGER DRIVE		TELEPHONE:	(714) 306-4068
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY: 6		CENSUS: 5	DATE:	07/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Moshe Davis, Administrator		TIME COMPLETED:	05:10 PM

NARRATIVE

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Licensing Program Analysts (LPA) Jenny Olson arrived unannounced to conduct a one year required annual. LPA met with Administrator and explained the reason for the visit.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The kitchen area was observed around 12 p.m. The facility has a sufficient supply of non-perishable and perishable food items. Cleaning supplies and disinfectants are stored in the garage and under the sink, inaccessible to clients. Knives are stored in a locked cabinet in the kitchen.

Common areas: Living and dining room furniture were observed to be in good condition except for a couch in the living room which needs to be replaced. There is a fireplace in the family room, which is screened and inaccessible. At 12:15 p.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced 7/21/2023.

The backyard has a covered outdoor area equipped with furniture for client use. No bodies of water noted. The washer and dryer are in the laundry room and in working condition.

Restrooms: The three client restrooms were clean and sanitary and in operating condition. The bathrooms were sufficiently stocked with soap and paper towels. Around 3:00 p.m., the hot water temperature measured at 114.2 degrees Fahrenheit.

Bedrooms: There are four (4) client rooms, which were furnished with appropriate linens and required furniture. A linen closet was located outside of the rooms, which stocked extra linens and towels.

Records: LPA reviewed client and staff records around 10:00 a.m. LPA reviewed five (5) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and needs and services plan. All files were complete. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BAUER RESIDENTIAL SANTA MARIA 4	FACILITY NUMBER: 425801936
	VISIT DATE: 07/13/2023

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LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 2 home. The last disaster drill was conducted on 7/4/2023.

Medications: Medications review began at 3:00 p.m.; medications are centrally stored and locked in a cabinet in the kitchen. Medications are labeled and checked for expiration dates. LPA advised the Administrator to ensure that all medication is properly documented on the CSMDR.

Infection Control: The facility has an infection control plan The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is adequate, dusting needs to happen more often. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

LPA interviewed Administrator around 4:15pm. All clients and staff were out in the community all day and unable to be interviewed.

LPA observed 2 staff were working at the facility prior to being transferred and associated. One staff was working without proper clearance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. A copy of the report, appeal rights, and civil penalties were printed and emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/13/2023 04:47 PM - It Cannot Be Edited

Created By: Jeannette Olson On 07/13/2023 at 03:53 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BAUER RESIDENTIAL SANTA MARIA 4	FACILITY NUMBER: 425801936
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80019(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1/16 staff were not cleared and 2/16 staff were not associated prior to working, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/13/2023
	Plan of Correction
1 2 3 4	Administrator agreed to take staff off the schdule until they are cleared and ensure staff are properly transfered and assoicated prior to working at the facility. POC is clear at the time of the visit.

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

LICENSING EVALUATOR NAME:

Jeannette Olson

LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC809 (FAS) - (06/04)

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