425802114-2-7-2023-29-AS-JOLN-CNU4LN-20230207181213

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802114
Report Date: 02/07/2023
Date Signed: 02/07/2023 06:12:56 PM

Document Has Been Signed on 02/07/2023 06:12 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:	GRANVIDA SENIOR LIVING AND MEMORY CARE		FACILITY NUMBER:	425802114
ADMINISTRATOR:	BRANDY MCCAULEY		FACILITY TYPE:	740
ADDRESS:	5464 CARPINTERIA AVE		TELEPHONE:	(805) 566-0017
CITY:	CARPINTERIA	STATE: CA	ZIP CODE:	93013
CAPACITY:	83	CENSUS: 50	DATE:	02/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Ted Burgess, Executive Director and Ashley Nash, Business Office Director, and Lumana Seide, Resident Care Director		TIME COMPLETED:	06:25 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 Analysts (LPAs) Olson and Phillips conducted an on-site 1 year infection control annual visit to the facility above on 2/7/2023 around 12:30 PM. LPAs met with Ted Burgess, Executive Director and Ashley Nash, Business Office Director and Lumana Seide, Resident Care Director and explained the purpose of the visit. LPAs took a physical plant tour of the facility with Business Office Director. 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 facility has multiple areas spaced to accommodate as much space as possible for social distancing. 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 are noted or any residents are showing any signs, symptoms or a temperature. Signs are posted in the front door and entry area regarding Covid-19. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff will 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. Resident Care Director is in charge of infection control and provides training and education to staff, residents and visitors. Staff will use full PPE with N95 masks and face shields when working with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for residents so isolation can be arranged when and if needed. The facility has single and double rooms and they are disinfected and wiped down weekly. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

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: GRANVIDA SENIOR LIVING AND MEMORY CARE	FACILITY NUMBER: 425802114
	VISIT DATE: 02/07/2023

NARRATIVE

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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/isolated resident rooms. Facility has a plan in place for when and whom to notify in an outbreak or other emergencies. Facility 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 and paper towels. Staff and resident records are kept in locked offices. 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.

At Approximately 1:15 PM LPA Olson observed 1 kitchen staff not wearing a mask and one staff in the common area wearing a mask on their chin, not covering their nose or mouth.

At approximately 2:10 PM, LPAs reviewed Guardian/Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined that seven staff is currently working in the facility that has not been finger print cleared and 2 staff were associated to the facility prior to their employment.

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

Exit interview conducted. Report, Civil penalties and Appeal Rights issued via email and printed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/07/2023 06:12 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRANVIDA SENIOR LIVING AND MEMORY CARE	FACILITY NUMBER: 425802114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or 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 3 staff were working with a pending clearance and 3 staff were working without being fingerprinted and 1 staff was fingerprinted on 2/6/23 but started work on 1/2/23, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/08/2023
	Plan of Correction
1 2 3 4	Administrator agrees that staff members will not work at this facility without receiving a criminal background/fingerprint clearance and will submit a plan to CCL to ensure staff are cleared and or associated prior to working. Administrator agreed to submit plan to CCL by 2/8/23

Type A

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 staff was not associated and 1 staff was associated on 2/1/23 but started working in the facility on 7/1/22, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/08/2023
	Plan of Correction
1 2 3 4	Administrator agrees that staff members will not work at this facility without an appropriate transfer and/or receiving a criminal background/fingerprint clearance and will submit a plan to CCL to ensure staff are cleared and or associated prior to working. Administrator agreed to submit plan to CCL by 2/8/23

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: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/07/2023 06:12 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRANVIDA SENIOR LIVING AND MEMORY CARE	FACILITY NUMBER: 425802114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80072(a)(2)

80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. 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 kitchen staff was not wearing a mask and 1 staff had a mask on their chin, bellow their nose ans mouth, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/08/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide training on Infection Control to staff and inform staff that they must wear masks in the facility at all times. Administrator agreed to submit training records with name, date and signiture to CCL by 2/8/23

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: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC809 (FAS) - (06/04)

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