425850225-12-12-2023-29-AS-JOLN-CYG3GV-20231212171457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850225
Report Date: 12/12/2023
Date Signed: 12/12/2023 05:15:15 PM

Document Has Been Signed on 12/12/2023 05:15 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:	FAMILY CONNECT MEMORY CARE SOLVANG		FACILITY NUMBER:	425850225
ADMINISTRATOR:	MAHAKIAN, LAUREN		FACILITY TYPE:	740
ADDRESS:	659 CHALK HILL ROAD		TELEPHONE:	(310) 383-1877
CITY:	SOLVANG	STATE: CA	ZIP CODE:	93463
CAPACITY:	6	CENSUS: 6	DATE:	12/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Virginia Rodriguez, Staff		TIME COMPLETED:	05:30 PM

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Licensing Program Analysts (LPA's) Olson and Miller arrived at the facility unannounced to conduct a required annual visit at 11:35 a.m. When LPA arrived, there were two staff and six residents present. LPA was greeted by Staff and informed them of the reason for the visit.

LPA's 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: Knives are stored in a locked drawer in the kitchen. Kitchen appliances were in operable condition. The facility did not have a sufficient supply of perishable food.

Common areas: Living and dining room furniture were observed to be in good condition. At 4:30 p.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. There is a fireplace in the dining room, which is screened and inaccessible. LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced 10/23/2023.

The backyard has a covered outdoor area equipped with furniture for client use. No bodies of water noted. The washer and dryer are in the laundry room. The laundry room is unlocked, the laundry soap is locked.

Restrooms: The two resident restrooms were clean and sanitary and in operating condition with non-skid stickers. The bathrooms were sufficiently stocked with soap and paper towels.

Bedrooms: There are three (3) resident rooms, which were furnished. A linen closet was located outside of the rooms, which stocked extra linens and towels.

Records: LPA reviewed resident and staff records around 11:45 a.m. LPA reviewed five (5) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All files were complete, 2 residents were missing Emergency consent forms. 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: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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: FAMILY CONNECT MEMORY CARE SOLVANG	FACILITY NUMBER: 425850225
	VISIT DATE: 12/12/2023

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LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. Files were not complete, staff stated they are working on printing them.

MEDICATIONS: Medications review began at 4:00 p.m. The medications are centrally stored and locked in a cabinet in the kitchen. Medications are labeled and checked for expiration dates. LPA advised the Staff to ensure that all the necessary information is properly documented on the CSMAR.

INFECTION CONTROL: 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’s policies and procedures as it pertains to infection control are adequate.

During today’s visit, the LPA obtained copies of the following: staff roster and current liability insurance.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

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