425850229-12-27-2023-29-AS-JOLN-CYWVUZ-20231227154535

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850229
Report Date: 12/27/2023
Date Signed: 12/27/2023 03:46:00 PM

Document Has Been Signed on 12/27/2023 03:46 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 TUNNELL		FACILITY NUMBER:	425850229
ADMINISTRATOR:	SORIANO, APRILYN A		FACILITY TYPE:	740
ADDRESS:	958 E TUNNELL STREET		TELEPHONE:	(805) 922-7670
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	6	CENSUS: 5	DATE:	12/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Aprilyn Soriano, Administrator		TIME COMPLETED:	03:50 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct a required annual visit at 11:15 a.m. When LPA arrived, there was two staff and five residents present. LPA was greeted by staff and Administrator shortly after and LPA informed them of the reason for the visit.

LPA 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 has a sufficient supply of perishable and non-perishable food.

Common areas: Living and dining room furniture were observed to be in good condition. At 1:30 p.m., carbon monoxide detector were tested and operational at the time of the visit. There is a fireplace in the living room, which is screened and inaccessible. LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced 11/1/2023.

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

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

Bedrooms: There are five (5) 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 11:20 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. 2/5 clients did not have a current needs and services plan.

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: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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: A CASA TUNNELL	FACILITY NUMBER: 425850229
	VISIT DATE: 12/27/2023

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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. Multiple staff were missing health screening and current first aid certification.

MEDICATIONS: Medications review began at 2:00 p.m. The medications are centrally stored and locked in a cabinet in the dining room. Medications are labeled and checked for expiration dates. LPA advised the Administrator 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 has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

At 2:45 p.m., LPA interviewed two (2) staff members and two (2) residents.

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

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D)

Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/27/2023 03:46 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: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and observation, the licensee did not comply with the section cited above in 2/2 staff present did not have current CPR or First Aid certification which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/03/2024
	Plan of Correction
1 2 3 4	Administrator agreed to get all staff CPR and First Aid Certification and send the certificate to CCL by 1/3/24

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2/5 staff do not have a health screening or TB test which posed a potential health and safety risk to persons in care.
	POC Due Date: 01/10/2024
	Plan of Correction
1 2 3 4	Administrator agreed to get all staff a health screening and or TB test and send the verification to CCL by 1/10/24

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

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