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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703158
Report Date: 06/22/2023
Date Signed: 06/22/2023 07:03:49 PM

Document Has Been Signed on 06/22/2023 07:03 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:SOLVANG FRIENDSHIP HOUSEFACILITY NUMBER:
421703158
ADMINISTRATOR:TAMMY WESTWOODFACILITY TYPE:
740
ADDRESS:880 FRIENDSHIP LANETELEPHONE:
(805) 688-8748
CITY:SOLVANGSTATE: CAZIP CODE:
93463
CAPACITY: 40CENSUS: 36DATE:
06/22/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Tammy Westwood, AdministratorTIME COMPLETED:
07:15 PM
NARRATIVE
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On 6/22/23 at 2:36 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced continuation visit to finalize the Annual/Required inspection started on 6/16/23. LPA met with Tammy Westwood, Administrator, and explained the purpose of the visit.

Medications are properly labeled and checked for expiration dates. One exception is that staff wrote on the label of Resident #1’s (R1) medications. Technical Violation given. A sampling of resident’s medication show they are centrally stored prescription and PRN medication which have been logged in the medications record with proper documentation from the residents’ doctors. R1's centrally stored medication list did not have the Date Started for three prescriptions started on 6/9/23, 6/20/23, 6/21/23. Technical Violation given.

Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for Medical Assessments, Needs and Service plans, Signed Admission Agreements and Pre-appraisals. There were no issues with resident files reviewed. Planned activities are offered to residents in care.


Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations/and current First Aid. The Administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate. Administrator states that “All managers have CPR training, one manager is on duty at all times, and there’s an on-call person with CPR training.” One out of five staff files reviewed indicate staff did not receive required Initial Training of 8 hours of Dementia, 4 hours of Postural Supports/Restricted Health Conditions/Hospice Care, 2 hours of Physical Limitations and Needs of Elderly, and 8 hours of Medications. Deficiency cited.

Exit interview conducted, deficiencies cited, and report and appeal rights given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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 06/22/2023 07:03 PM - It Cannot Be Edited


Created By: Darlene Chavez On 06/22/2023 at 06:45 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: SOLVANG FRIENDSHIP HOUSE

FACILITY NUMBER: 421703158

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(c)(8)
Other Provisions
(c) The training shall include, but not be limited to, all of the following: (8) The special needs of persons with Alzheimer’s disease and dementia, including nonpharmacologic, person-centered approaches to dementia care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review, the licensee did not comply with the section cited above in one out of five staff files reviewed indicate that staff did not receive full Initial Training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2023
Plan of Correction
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Licensee will ensure that staff receive full Initial Training and send documentation showing this was completed by 6/29/23.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2023
Plan of Correction
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Licensee will complete the emergency disaster plan and send to CCL by 6/29/23.
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:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


LIC809 (FAS) - (06/04)
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