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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850229
Report Date: 11/16/2022
Date Signed: 11/16/2022 06:57:54 PM


Document Has Been Signed on 11/16/2022 06:57 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:A CASA TUNNELLFACILITY NUMBER:
425850229
ADMINISTRATOR:SORIANO, APRILYN AFACILITY TYPE:
740
ADDRESS:958 E TUNNELL STREETTELEPHONE:
(805) 922-7670
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 5DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Aprilyn Soriano, Administrator/LicenseeTIME COMPLETED:
07:00 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 11/16/2022 2:45 PM. LPA met with Administrator/Licensee and explained the purpose of the visit.

LPA took a physical plant tour of the facility with Administrator. The facility has not submitted an Infection Control Plan to the department, Technical Assistance was issued. 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. Signs are posted in the front door and entry area regarding Covid-19. 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/Licensee 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 single and double rooms that 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
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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: A CASA TUNNELL
FACILITY NUMBER: 425850229
VISIT DATE: 11/16/2022
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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 cabinet. 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. Administrator Certificate is valid. The facility has working smoke and carbon monoxide detectors present in the facility.



At Approximately 2:50 PM LPA observed 2 staff in the facility to not be wearing masks.

At Approximately 3:05 PM LPA observed 2 fire extinguishers charged but last inspected on 09/09/2021



At approximately 4 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.

LPA observed 2 staff working were not on the Staff roster and Administrator stated they had a lot of turn over and is hard to keep updated. Staff were fingerprint cleared and associated. Administrator will submit a updated LIC 500 to CCL.

Pursuant to Title 22 Division 6 Chapter 1 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).



Exit interview completed, copy of report and appeal rights were emailed and mailed to Administrator/ Licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/16/2022 06:57 PM - It Cannot Be Edited

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: A CASA TUNNELL
FACILITY NUMBER: 425850229

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(2)
80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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 in 2 out of 2 staff were not wearing masks in the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2022
Plan of Correction
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Administrator agreed to provide training on Infection Control to staff and review latest CCL PINS that state staff must wear masks in the facility at all times. Administrator agreed to submit records to CCL by 11/17/22
Type A
Section Cited
CCR
87203
87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

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 in 2 out of 2 fire extinguishers were not inspected annualy, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2022
Plan of Correction
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Administrator agreed to submit a plan to CCL on how they will insure fire extinguishers are inspected annually.

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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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