425850204-2-27-2023-29-AS-RDLN-CPFS8F-20230227123904

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850204
Report Date: 02/27/2023
Date Signed: 02/27/2023 12:39:12 PM

Document Has Been Signed on 02/27/2023 12:39 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:	MISSION VILLA		FACILITY NUMBER:	425850204
ADMINISTRATOR:	NEWQUIST, DANA		FACILITY TYPE:	740
ADDRESS:	321 W MISSION STREET		TELEPHONE:	(805) 898-2709
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93101
CAPACITY:	14	CENSUS: 12	DATE:	02/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Emily Gerr, Administrator		TIME COMPLETED:	12:45 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 Analyst (LPA) De Leon conducted an on site 1 year infection control annual visit to the facility above on 02/27/2023 at 9:00 AM . LPA met with Emily Gerr, Administrator and explained the purpose of the visit. Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department. The facility has an entry point at the front door where everyone entering completes sign-in and symptom screening questionnaire. All documentation is kept in a binder. The entry station has hand sanitizer along with a thermometer. All equipment and PPE supplies are kept in the hallway cupboard. Medications are kept in a locked hallway cupboard. The dining area can accommodate distancing between residents when eating meals. The staff screen residents at a minimum of 1 x a day. Increased monitoring is conducted if any change of conditions is noted.. Signs are posted in the common areas through out the facility regarding Covid-19. All required postings are hung in common areas of the facility. Staff makes sure residents 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 residents. Facility has several areas for visiting inside, outside and in rooms. 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 will be tested and negative results received before 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. Emergency Disaster plan has all agencies with telephone numbers listed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

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: MISSION VILLA	FACILITY NUMBER: 425850204
	VISIT DATE: 02/27/2023

NARRATIVE

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Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility staff will be assigned to only work with those quarantined/isolated individuals. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. Residents rooms all have own sinks. The facility has 12 bedrooms and 5 resident rest-rooms, hand washings signs are posted with supplies of soap and paper towels. 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. Trash bins have tight fitting lids. Facility has plans for delivering medications and meals to any quarantined/isolation room. The facility has proper cleaning and disinfectant sprays. 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. Activities have been modified to individuals or small groups with social distancing. Furniture has been moved around to accommodate social distancing between staff and residents as much as it can be. 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. Staff and Resident records are kept in the locked staff office and electronically. Old resident binders are kept locked in hallway closet. 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. Smoke and Carbon Monoxide detectors are present. Administrator certificate expire 02/14/2024.
No deficiencies observed during the visit and all infection control protocols are implemented and being followed.

Exit interview completed and report printed and given to Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

LIC809 (FAS) - (06/04)

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