405801406-10-17-2024-29-AS-RDLN-DA5UUQ-20241017155355

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801406
Report Date: 10/17/2024
Date Signed: 10/17/2024 03:54:10 PM

Document Has Been Signed on 10/17/2024 03:54 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:	HERITAGE RESIDENCE		FACILITY NUMBER:	405801406
ADMINISTRATOR/ DIRECTOR:	LING H. MANUEL		FACILITY TYPE:	740
ADDRESS:	1724 BADEN AVENUE		TELEPHONE:	(805) 473-0425
CITY:	GROVER BEACH	STATE: CA	ZIP CODE:	93433
CAPACITY: 4		CENSUS: 3	DATE:	10/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Ling Manuel, Administrtor		TIME VISIT/ INSPECTION COMPLETED:	04:00 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 1:00 pm to conducted a 1 year annual visit to the facility above. LPA met with Administrator Ling Manuel 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 an Infection Control Plan on file. 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. Quarantined or isolated individuals will have meals and medication delivered to rooms when and if needed. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and waste baskets have tight fitting covers. Physical Plant & Environment Safety: The facility has 4 resident bedrooms and 2 resident bathrooms currently occupying 3 residents and employs 8 staff. The facility has 1 bedroom for live-in staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents are locked under the kitchen sink and in the locked garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with an umbrella for shade. Telephone and internet service is provided for resident use. The facility has a working washer and dryer. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

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: HERITAGE RESIDENCE	FACILITY NUMBER: 405801406
	VISIT DATE: 10/17/2024

NARRATIVE

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Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 09/11/2025. The facility is approved for a capacity of 4 with 4 Non-Ambulatory of which 1 may be bedridden in bedroom #2. Hospice approved for 3.

Staffing: The facility employes 2 full time live in staff, 4 back up staff, 1 administrator and 1 back up Administrators. Staff records are kept confidential. LPA reviewed 4 staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate expired 09/23/2024, renewal application has been submitted and is pending. Back up Administrator Administrator Certificate Expires 11/23/2025.

Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 4 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness, policy, procedures, infection control, and PPE requirements. Quarterly Disaster Drills are completed. Staff handling medications had annual training. Trainers met the requirements to train staff with required information present in files. Hospice and Home Health had training records on file.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Three 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 accepting them into care. The Facility does not handle cash resources for any of the residents 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 is posted. Visitation policy is posted at entry. Internet is provided to residents in care with confidentiality and privacy.
Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

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: HERITAGE RESIDENCE	FACILITY NUMBER: 405801406
	VISIT DATE: 10/17/2024

NARRATIVE

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Food Service: 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. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff were observed for personal hygiene and food sanitation practices.

Incidental Medical Services: Facility provides transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). Medications for all resident in care are centrally stored. LPA reviewed medications and records. No medications label were altered, medications were checked for expiration dates and medications were given as prescribed with physicians orders.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. 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. Facility has emergency food and water supply, flash lights with batteries, and a cooler with ice packs for medications. The facility has two evacuation locations and a three places available for a back up generator if sheltering in place.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have any residents currently using oxygen. The facility currently has 3 resident receiving hospice services. The facility currently does not have resident receiving home health services. Hospice care plans are kept on file and up to date. The facility does not have any delayed egress. The facility has two self latching, self closing gates with alarms. 1 gate is in need of repair to self latch again. All exiting doors and gates are alarmed. There are no bodies of water on the premises.

LPA conducted interviews with 2 staff and 2 residents.

Exit interview conducted and copy of report printed for Administrator

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

LIC809 (FAS) - (06/04)

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