405801283-5-7-2026-29-AS-RDLN-DTUVHS-20260507162735

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801283
Report Date: 05/07/2026
Date Signed: 05/07/2026 04:28:42 PM

Document Has Been Signed on 05/07/2026 04:28 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:	ALDER HOUSE		FACILITY NUMBER:	405801283
ADMINISTRATOR/ DIRECTOR:	TODD TOSE		FACILITY TYPE:	740
ADDRESS:	295 ALDER STREET		TELEPHONE:	(805) 489-1266
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY: 32		CENSUS: 22	DATE:	05/07/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	Todd Tose, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:15 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 arrived at 10:15am to conducted a 1 year annual visit to the facility above. LPA met Administrator Todd Tose and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environment Safety: The facility is has 23 bedrooms and 23 bathrooms and 2 of those bedrooms with a shared bathroom, and 1 common area restroom. The facility currently has 22 residents and employs 21 staff and 1 Administrator. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has a carbon monoxide detector, smoke alarm and sprinkler system. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen has a tap with hot water and warning sign is posted. The showers have non-skid textured floors. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The facility has a signal system in each residents room. The pathways are clear of any obstructions, well lit and equipped with hand railings where needed on ramps and porches. Fire places has screened coverings. Disinfectant, cleaning solutions and poisons are inaccessible to clients in care. The facility has sufficient space inside and outside for activities and visiting. The facility has telephone and internet service for resident use. Continued 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: ALDER HOUSE	FACILITY NUMBER: 405801283
	VISIT DATE: 05/07/2026

NARRATIVE

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Operational Requirements: The facility has a current plan of operation with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 02/01/2027. The facility is approved for a capacity of 32 Non-Ambulatory and has a current Hospice wavier granted for 6.
Staffing: The facility employes 21 staff and 1 Administrator. Staff records are kept confidential. Staff records were reviewed for 5 staff and 1 Administrators. Staff records had finger print clearance and associations with criminal record statements, personnel record or applications, First Aid and CPR certificates and Health screening with TB results. Facility employs sufficient and competent staffing for resident care, cooking, housekeeping, office work and maintenance of building and grounds. The facility has sufficient night staff on duty. Staff are trained to effectively interact with emergency personnel and provide residents medical records to emergency responders. Administrator Certificate is valid.
Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records which were current for 2025-2026 initial /or annual training requirements. Staff have been fingerprinted with criminal record clearances or exemptions. Administrator meets continuing education requirements for renewal of administrator certificate. Trainers meet the education and experience requirements. Staff training documents have trainers name, address, phone numbers, topic or subject matters, times, dates and hours.
Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before excepting them into care. The Facility does not handle cash resources for any resident in care. Facility does submit incident reports to the department when required.
Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license along with CCL reports and PIN's were posted. Visitation policy is posted at entry.

Continued 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

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: ALDER HOUSE	FACILITY NUMBER: 405801283
	VISIT DATE: 05/07/2026

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Planned Activities: The facility offers activities to all residents in care. The facility employs an Activities Director and a monthly calendar with all activities is posted. The facility also offers additional activities to include books, magazines, newspapers, television, daily walks, group discussions and communications, games and puzzles. The facility has a piano for resident use and musicians come to entertain residents. The facility has sufficient space to allow for activities indoors and outdoors as well as an activity room.
Food Service: The facility employs food service staff. The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. A menu is posted for residents in care. Modified diets prescribed by a physician are followed for those residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices.
Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed for the Centrally Stored Medication and Destruct Records (CSMDR) and Medication Administrator Records (MAR). LPA completed a full audit on all residents medication, all medications were in original containers, prescription labels were not altered, and no medications was expired.
Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 07/17/2025. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.
Residents with Special Health Needs: The facility does not accept dementia residents in care. The facility does not have delayed egress. The facility does have 1 resident with oxygen and required signs are posted. The facility has no hospice residents in care. Hospice care plans will be kept on file and up to date. The facility does not have residents on Home Health services and plans will kept up to date.

LPA conducted interviews with 4 Residents and 1 staff.

Exit interview conducted and copy of report emailed to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC809 (FAS) - (06/04)

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