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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801055
Report Date: 03/29/2023
Date Signed: 03/29/2023 01:12:45 PM

Document Has Been Signed on 03/29/2023 01:12 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:BAYWOOD MANOR RCFE IIFACILITY NUMBER:
405801055
ADMINISTRATOR:GUILLERMA M.PACAOANFACILITY TYPE:
740
ADDRESS:1090 PASO ROBLES AVENUETELEPHONE:
(805) 528-5305
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY: 6CENSUS: 4DATE:
03/29/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Wilfred "Eddie" Pacaoan, LicenseeTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst's (LPA's) De Leon and Chavez conducted a Case Management Annual Continuation to the facility above. LPA met with Wildfred Pacaoan, Licensee and explained the purpose of the visit.

LPA's reviewed 4 staff files all required forms were present, Personnel Record, 1st Aid & CPR, Fingerprint clearance and associations, Criminal Records Clearance, and Health screening with TB results.

LPA's reviewed Staff Training Records, all training records were present with a total of 18 hours completed and missing 2 hours annually covering hospice care and psycho-tropic medication which is required.

LPA's reviewed 4 residents medications, medication reviewed were current on the CSMDR and MAR for 3 residents in care. One resident had a wrong expiration date on the CSMDR and 1 medication was not written on the MAR as prescribed by the physician. Staff corrected both CSMDR and MAR errors on visit.

Exit interview conducted, Deficiency cited, Technical Violations issued, copy of report and appeal rights issued to Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
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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Document Has Been Signed on 03/29/2023 01:12 PM - It Cannot Be Edited


Created By: Rachael De Leon On 03/29/2023 at 12:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BAYWOOD MANOR RCFE II
FACILITY NUMBER: 405801055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have 2 of the 20 annual training hours completed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2023
Plan of Correction
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Administrator agreed to train for 2 hours covering hospice and psychotropic medications to fufill the 20 hours of annual trianing requirement. Send all staff signature with training certificate to CCL.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Rachael De Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023


LIC809 (FAS) - (06/04)
Page: 31 of 36