425850081-12-19-2023-29-AS-EMIR-CYP35Z-20231219165734

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850081
Report Date: 12/19/2023
Date Signed: 12/19/2023 04:59:10 PM

Document Has Been Signed on 12/19/2023 04:59 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	STADIUM PLACE HOME		FACILITY NUMBER:	425850081
ADMINISTRATOR:	CINDY BAKER		FACILITY TYPE:	734
ADDRESS:	961 STADIUM PLACE		TELEPHONE:	(805) 691-9036
CITY:	SOLVANG	STATE: CA	ZIP CODE:	93463
CAPACITY: 5		CENSUS: 5	DATE:	12/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Cindy Baker, Administrator		TIME COMPLETED:	05:20 PM

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

LPAS 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 facility has a sufficient supply of non-perishable and perishable food items. Cleaning supplies and disinfectants are stored and locked in a cabinet under the sink and inaccessible to clients. Knives are stored in a locked drawer.

Common areas: Living and dining room furniture were observed to be in good condition. LPAs observed required postings throughout the common space. The fire extinguishers were charged.

The backyard has a covered area for shade and is equipped with furniture for client use. No bodies of water noted. The washer and dryer are in the garage and locked.

Restrooms: The three client restrooms were clean and sanitary and in operating condition. The bathrooms were sufficiently stocked with soap and paper towels. Around 1:00 p.m. the hot water temperature measured in the kitchen at 117.0 degrees Fahrenheit.

Bedrooms: There are five (5) client rooms, which were furnished with appropriate linens and required furniture. A bedroom closet was stocked with extra linens and towels.

Records: LPAs reviewed client and staff records from 10:00 a.m. to 12:00 p.m. LPAs 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 plans. All files were complete.

Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: STADIUM PLACE HOME	FACILITY NUMBER: 425850081
	VISIT DATE: 12/19/2023

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sLPAs 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 an Adult Residential Facility for Persons with Special Health Care Needs. The last disaster drill was conducted on 12/18/23.

Medications: Medications review began around 4:00 p.m. medications are centrally stored and locked in various carts. Medications are labeled and checked for expiration dates. LPAs advised the Administrator to ensure that all the necessary information is properly documented on the CSMAR.

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 sufficient. The facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

LPAs interviewed 1 resident around 3:30 p.m. and 2 staff at 3:00 pm. The other 4 clients are non-verbal.

Exit interview conducted. A copy of the report was printed and emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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