405802555-5-12-2021-29-AS-RDLN-C2XU7G-20210512151956

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802555
Report Date: 05/12/2021
Date Signed: 05/12/2021 03:20:39 PM

Document Has Been Signed on 05/12/2021 03:20 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:	SOUTHLAND HOME		FACILITY NUMBER:	405802555
ADMINISTRATOR:	VALDEZ, KATHYRINE		FACILITY TYPE:	740
ADDRESS:	804 SOUTHLAND ST		TELEPHONE:	(805) 929-5096
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY: 4		CENSUS: 2	DATE:	05/12/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Llamina Ruiz/House Manager		TIME COMPLETED:	12:30 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's (LPA's) De Leon, Jeffries and Tuong conducted an onsite 1 year infectious control annual visit to the facility above. LPA's met with Llamina Ruiz, House Manager and explained the purpose of the visit. House Manager took LPA's on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening all staff, residents returning from an outing, and visitors wanting to come into the facility. All documentation is kept on a clipboard and filed in binder daily. The entry station has PPE, hand sanitizer and disinfecting wipes along with a thermometer. The facility has a large living room area that is used for eating, activities and exercise all areas are spaced to accommodate 6 foot social distancing. All equipment and supplies are kept in a cabinet, LPA's recommended keeping the cabinet locked when not in use and based on what supplies are being kept in it daily. The kitchen area has a small dining area and magnetic locks on cupboards. LPA's suggested testing all magnetic locks for wear and replacing any that are not working properly and to secure the magnetic key for staff access only. LPA recommended painting walls that had more than regular wear and tear. The staff screen residents for symptoms and temperature 3 x's a day and documentation is kept in residents file. Increased monitoring is conducted if any change of condition is noted or any residents is showing any signs, symptoms or has a temperature. Signs are posted on the hallway walls regarding Covid-19 symptoms to report to staff, coughing and sneezing etiquette, hand hygiene, mask wearing and social distancing. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

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: SOUTHLAND HOME	FACILITY NUMBER: 405802555
	VISIT DATE: 05/12/2021

NARRATIVE

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The two residents currently in the facility do not wear masks at all times, staff gives constant reminders and makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility has several areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. The Facility has hand sanitizer located thorough out the house and in residents rooms. LPA cautioned House Manager to keep an eye on new admits and to review the LIC 602 if the resident is able to have grooming and hygiene products, if they are not able to have then the facility will need to arrange for these items to be locked or inaccessible to 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 staff are conducting surveillance testing of 25% of staff every 7 day on a rotation bases. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Facility House Manager is in charge of infection control and she provides training and education to staff, residents and visitors. House Manager is in charge of staffing and works with facility Licensee on any issues or additional coverage. Staff are assigned a resident and daily duties upon arrival to each shift. Staff only provide care and supervision to the resident assigned. If any suspected or confirmed cases of Covid-19 are found in the facility staff will be assigned to only work with those quarantined/isolated individuals and will not work with other individuals until cleared by Health Department to do so. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate single rooms for each resident so isolation can be arranged when and if needed. The facility has 2 restrooms for resident use and can designate one of those as an isolation restroom. Signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. PPE supplies are kept in the office accessible to all staff. Facility has a 30 day supply of PPE on hand. Trash bins had tight fitting lids. Facility has plans for delivering medications and meals to any quarantined/isolation room. The facility has proper cleaning and disinfectant sprays and wipes.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

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: SOUTHLAND HOME	FACILITY NUMBER: 405802555
	VISIT DATE: 05/12/2021

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The facility has not been fitted tested for N95 masks and LPA explained in an outbreak the facility would need to be wearing N95 and would require being fit tested for those masks. LPA's highly recommended House Manager works with Licensee to get the staff fit tested for the N95 masks before an outbreak. Facility House manager has a plan in place for when and whom to notify in an outbreak or other emergencies. House Manager keeps a line list of all tested staff or 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. Activities have been modified to individuals or small groups with social distancing. Furniture has been moved around to accommodate social distancing between staff and residents. Residents medication is in bubble packets and is delivered in 30 day supply 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 locked in the staff office. Office and other break room available for staff to use individually and is cleaned after each use. LPA's reminded House Manger of a change in administrator and the request for documentation to make that change with in the next 30 days. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health department orders should be followed to remain in compliance.

LPA De Leon reviewed infection control and observations made at the facility with House Manager. LPA's provided best practices and guidance for the facility to remain in compliance.

Exit interview completed, copy of report emailed to House Manger for signature and return by mail at the Goleta office.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

LIC809 (FAS) - (06/04)

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