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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802130
Report Date: 02/22/2023
Date Signed: 02/22/2023 12:57:14 PM

Document Has Been Signed on 02/22/2023 12:57 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:DOCTOR'S RESIDENTIAL CARE FACILITYFACILITY NUMBER:
425802130
ADMINISTRATOR:GILL, NATASHAFACILITY TYPE:
735
ADDRESS:925 W. CLARENCE CT.TELEPHONE:
(805) 623-5490
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 4CENSUS: 3DATE:
02/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Natasha Gill, Administrator/LicenseeTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Olson conducted an on-site 1 year infection control annual visit to the facility above on 2/22/2023 around 09:40 AM. LPA was accompanied by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Miguel Magania. LPA and QAS met with Administrator/Licensee and explained the purpose of the visit.

LPA and QAS took a physical plant tour of the facility with Staff and Administrator. The facility has submitted an Infection Control Plan to the department. The facility has an entry point at the front door where everyone entering completes 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 as needed. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature. 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.

Administrator 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 double and single rooms and they are disinfected and wiped down daily. 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. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: DOCTOR'S RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 425802130
VISIT DATE: 02/22/2023
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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, and paper towels. Staff and resident records are kept in a locked office. 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. Fire extinguisher was charged and inspected annually. The facility has working smoke and carbon monoxide detectors present in the facility.



At approximately 12:20 pm, LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS)/Guardian, Facility Personnel and facility staff roster and determined that all staff are fingerprint cleared and associated to the facility.

At approximately 9:45 AM LPA and QAS observed staff 1 (S1) to lock the knife and chemical cabinets.

All infection control protocols are being followed.


Exit interview completed copy of report and appeal rights was emailed and printed
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
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Document Has Been Signed on 02/22/2023 12:57 PM - It Cannot Be Edited


Created By: Jeannette Olson On 02/22/2023 at 12:32 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: DOCTOR'S RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 425802130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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
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Based on observation, the licensee did not comply with the section cited above when the knife and chemical cabniet was unlocked, which poses an immediate health, safety risk to persons in care.
POC Due Date: 02/23/2023
Plan of Correction
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Administrator agreed to hold a training on regulation 80087 and the importance of locking hazardous items and send proof of training with staff name, date, and signiture to LPA. Administrator will schedule the training by 2/23/23
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023


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