Somis Living I

Type of visit: Required - 1 Year

At 09:00 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Administrator Jocelyn Cacal and informed them of the reason for the visit. At 09:23 a.m. the LPA conducted a tour of the physical plant with Administrator Jocelyn to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of five (5) resident rooms, one (1) staff room, two resident bathrooms and two staff bathrooms. The LPA observed fire extinguishers throughout the facility, which were purchased on 7/17/2023 and fully charged. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallway near the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen: During the facility tour at 9:25 a.m. the kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents. Sharps and cleaning supplies are stored in locked drawer and cabinet. Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. At 9:37 a.m. the LPA observed prescribed medication Polyethylene Glycol inside the unlocked staff room, accessible to residents in care. Upon observation the administrator locked the staff room. At 9:45 a.m. the LPA observed over the counter nasal spray, eye drops, bar of soap, and CryoDerm pain reliever roll in a small bag inside the nightstand of one of the residents (R1) in room 5, accessible to the residents in care. Upon observation, the administrator stored all items from room 5 inaccessible to the residents. Report will continue on LIC809-C. Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. At 02:44 p.m., water temperature in one of the restrooms was measured at 119.0 degrees Fahrenheit. During the visit the LPA observed both resident restrooms inside the residents rooms, room 5 being used as a passageway for residents in rooms 2,3 and 4. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the living room, which is covered with a screen. facility maintained a comfortable temperature of 76 degrees. There were no obstructions and/or tripping hazards throughout the facility. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Parking is available for visitors. There are no bodies of water on the premises. Infection Control: The community has an adequate supply of Personal Protection Equipment (PPE) and can obtain additional supplies. The community's cleaning protocol is sufficient. If needed, the facility has the capacity to designate isolation rooms if there is a confirmed case of COVID-19. The community's policies and procedures pertaining to infection control were adequate. Record Review: At 11:06 a.m. a review of facility files was initiated. The LPA observed documentation of Infection Control, Disaster prevention and obtained Client and Staff rosters. The LPA reviewed five (5) out of (5) resident Files and five (5) out of twelve (12) staff files. All documents reviewed appeared complete and current. Medications: At 1:07 p.m. a medications review was initiated. Medications are centrally stored and locked in a locked cabinet in the living area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. Interviews: The LPA conducted two (2) client Interviews and two (2) staff interviews. No immediate concerns were voiced during the visit. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Administrator Jocelyn Cacal.the state’s words, verbatim · CDSS document, Aug 11, 2023

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) JoAnn Rosales conducted a pre-licensing visit to the above noted facility. The LPA met with applicant Jocelyn Cacal. This is a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver for 4 has been approved. Component III was conducted in conjunction with this pre-licensing visit. The facility is a one story. A physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for 6 non-ambulatory residents of which 1 may be bedridden. The facility has 4 private resident bedrooms, Rooms #1, 2, 3, and 4 and 1 shared room, Room #5. Rooms #1 and 5 have direct exits to the outside. Room #1 is an approved bedridden room. The facility does not have fire sprinklers. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with comfortable mattress and clean linen; which includes, top and bottom linens, pillowcases, and blankets. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is 1 staff room. All rooms were free of odors. All window screens were clean and maintained in good repair. There are 2 staff bathrooms in the hallway. Their are 2 resident bathrooms with showers and non-skid mats. The toilets and showers have grab bars. The facility has 2 water heaters and the hot water tested in the resident bathrooms at 119 and 108.4 degrees F. which falls within the allowable range of 105 degrees F to 120 degrees F. Resident and staff records are stored in locked cabinets in the family room. Medications are centrally stored in a locked filing cabinet in the office. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in a hallway cabinet inaccessible to residents. Kitchen knives are stored in a locked drawer in the kitchen. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at 0 degrees F. and the refrigerator was maintained at 42 degrees F. The supply of nonperishable food is adequate. There are no pesticides, poisons or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked garage cabinet. No flies or other vermin were observed. The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and activity supplies in the family room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non-private bathrooms. There is a fireplace in the family room. It is screened and there are no tools. Alarms on all exterior doors were functional at time of visit. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. The facility smoke alarm system is hard wired. There is a pull station at the front entry of the house. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There are 2 fully charged fire extinguishers throughout the house. The laundry area is located in the garage. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a hallway closet. Extra incontinence supplies are stored in the garage. There is a functioning telephone on the premises. The emergency exiting plans are located throughout the facility. The facility sketch is posted in the entryway hallway. The emergency telephone numbers are posted in entryway hallway. Other required postings are posted in the entryway hallway. The exterior passageways were clean and clear of any obstructions. There is a shaded area in the front of the house with tables and chairs where residents can sit. The entire property is fenced. There is a driveway gate with a call box for entry. There is another house located in the back of the property which is currently licensed as Somis Living II #565802414. There are no bodies of water on the premises at the present time. The garage is accessible from the house. There was a staff in the garage doing laundry at the time of visit. Applicant stated that they do lock the garage door. The following item must be corrected prior to licensure. Submit proof of corrections, along with a copy of this report, to LPA JoAnn Rosales, so that your application may be completed: Photo of refrigerator temperature reading at 40 degrees F. or less. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.the state’s words, verbatim · CDSS document, Aug 16, 2022

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 6 COMP II Participants: Jocelyn Cacal (Applicant/Licensee, Administrator) Interview Method: Telephone interview On 7/15/11, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jul 15, 2022