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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802138
Report Date: 09/26/2022
Date Signed: 09/26/2022 03:54:24 PM

Document Has Been Signed on 09/26/2022 03:54 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:TELECARE AGNES AVENUEFACILITY NUMBER:
425802138
ADMINISTRATOR:PHILLIP JONESFACILITY TYPE:
772
ADDRESS:116 AGNES AVENUETELEPHONE:
(805) 457-3724
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 10CENSUS: 8DATE:
09/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Hanna Diaz, Team Lead and Amber Trigueros, Clinical DirectorTIME COMPLETED:
04:00 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 09/26/2022 at 2:00 PM. LPA met with Amber Trigueros-Clinical Director and Hanna Diaz, Team Lead and explained the purpose of the visit.

LPA took a physical plant tour of the inside and outside of the facility with Staff.
The facility has an entry point at the front door where everyone entering completes sign-in, symptoms screening and temperature check for all staff and visitors wanting to come into the facility. All documentation is kept in a file.

The staff screen residents for symptoms and temperature 1x 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 on the front door, entry area regarding Covid-19. Staff makes sure clients 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 clients.

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. Responsible Parties and agencies are notified by facility when required.

Continued 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2022
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: TELECARE AGNES AVENUE
FACILITY NUMBER: 425802138
VISIT DATE: 09/26/2022
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The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. The nursing team is in charge of infection control and provides training and education to staff, residents and visitors.

If any suspected or confirmed cases of Covid-19 are found in the facility a staff will use PPE supplies that 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 or isolated resident room. The facility has proper cleaning and disinfectant policies. Facility has a plan in place for when and whom to notify in an outbreak or other emergencies. Staff 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. Activities have been modified to individuals or small groups with social distancing. 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 not well stocked with soap, paper towels and hand washing signs, they were immediately filled and a technical assistance was given. Staff and resident records are kept in locked room. 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. The most stringent orders should be followed by any of these agencies. Fire extinguishers are charged and inspected annually.

At approximately 3:00 pm, LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined that all staff are fingerprint cleared and associated to the facility


Exit interview completed and copy of report emailed to Administrator/Regional Director.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC809 (FAS) - (06/04)
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