405850052-3-20-2024-29-AS-RDLN-D3K2TX-20240320174128

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850052
Report Date: 03/20/2024
Date Signed: 03/20/2024 05:41:59 PM

Document Has Been Signed on 03/20/2024 05:41 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:	PARK PLACE ASSISTED LIVING		FACILITY NUMBER:	405850052
ADMINISTRATOR:	BARNHILL, DIANA		FACILITY TYPE:	740
ADDRESS:	7500 PORTOLA RD		TELEPHONE:	(805) 591-9855
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY: 13		CENSUS: 12	DATE:	03/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Diana Barnhill, Administrator		TIME COMPLETED:	05:41 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 10:30am to conducted a 1 year annual visit to the facility above. LPA met with Administrator Diana Barnhill 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 a current Infection Control Plan. The facility has a sign in and out clipboard 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. 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 is a 10 bedroom with 10 bathrooms, 3 common restrooms, kitchen, dining room, laundry room, activity room, locked office with medication locked closet currently occupying 13 residents and employs 12 staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has dual 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. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. 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 in care locked in basement, cleaning closet and laundry rooms. The facility has sufficient space inside and outside for activities and visiting. The facility has an enclosed courtyard for client use with plenty of shade. The facility has telephone and internet service for resident use. The facility has video surveillance in the common areas without voice or sound capability for privacy purposes. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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: PARK PLACE ASSISTED LIVING	FACILITY NUMBER: 405850052
	VISIT DATE: 03/20/2024

NARRATIVE

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Operational Requirements: The facility has a current plan of operation on file. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 09/28/2024. The facility is approved for a capacity of 13 with 13 Non-Ambulatory of which 12 may be bedridden. Hospice approved for 8.

Staffing: The facility employes 11 staff and 1 Administrators. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. Administrator Certificate expired 08/2023 waiting on renewal process.

Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training with all subjects covered over a 3 year period, 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 and procedures, infection control requirements and Quarterly Disaster Drills. Staff handling medications had annual training of 8 hours of medication training. Hospice and Home Health provide training to staff for residents under those services and facility keeps records on file.

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 accepting them into care. The Facility does not handle cash resources on residents in care. Facility does submit incident reports to the department when required.

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. Emergency supply of food and water is available. 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 are observed for personal hygiene and food sanitation practices. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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: PARK PLACE ASSISTED LIVING	FACILITY NUMBER: 405850052
	VISIT DATE: 03/20/2024

NARRATIVE

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Incidental Medical and Dental Services: Facility provides or assists in providing 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 are kept in a locked medication closet in office. Medication were checked for expiration. Medication labels were not altered and medication were stored in original containers. Administrator and Medication Technicians destroy medications by logging and taking to the pharmacy for destruction.

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. Internet and a device for residents use is provided to resident with confidentiality and privacy.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers was charged and last inspected 08/04/2023. 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 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 currently have residents with oxygen. The facility has 3 hospice residents in care. Hospice care plans are kept on file and up to date. The facility currently has 2 residents receiving Home Health services. Home Health services records are kept on file. The facility does not have delayed egress. The facility has a key coded exit on the front exterior door. The facility has exiting door alarms.

LPA conducted interviews with 2 residents and 2 staff.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC809 (FAS) - (06/04)

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