Annette Lodge

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rachael De Leon arrived at 10:30am to conducted a 1 year annual visit to the facility above. LPA met Administrator Stephanie Avila 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 submitted an Infection Control Plan to the department. The facility has a sign in and out kiosk for Staff, Residents and visitors. The bathrooms have toilet paper, paper towels, and hand soap. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Staff are trained on infection control and the use of Personal Protective Equipment (PPE) on hire and annual there after. Physical Plant & Environment Safety: The facility is 14 bedroom with 14 private bathrooms and 1 common areas restrooms currently occupying 13 residents and employs 15 staff of which 3 certified Administrators. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors, hard wired with sprinkler system. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid textured floors or mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The facility has a pendant system and pull cords in each residents bathroom. All pathways are clear of any obstruction. 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 are conducted. Continued 809-C Staff handling medications had initial and/or annual training of 8 hours of medication training. Kitchen staff had training on facility policy and procedures for food handling and preparation as well as infection control requirements, some staff had food handler certificates. Trainers met the requirements to train staff with required information present in files. Hospice and Home Health care plans had training records on file. Staffing: The facility employes 15 staff and 3 Administrator. Staff records are kept confidential. LPA reviewed 5 random 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 expires 01/08/2028. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. 5 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. 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 along with CCL report. Internet is provided to each resident with confidentiality and privacy. Planned Activities: The facility offers activities to all residents in care. The facility employs an Activities Director and a monthly calendar with all activities is posted. The facility also offers additional activities to include books, magazines, newspapers, television, daily walks, group discussions and communications, games and puzzles. The facility has sufficient space to allow for activities indoors and outdoors. Food Service: The facility employs food service staff. 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. A menu is posted for residents in care. Modified diets prescribed by a physician are followed for those residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. Kitchen Cook has a valid Food Handler Certificate. Continued 809-C Incidental Medical & Dental: The facility has a medication carts that are kept locked in locked medications closets. Facility provides transportation to medical and dental appointments when needed. The facility uses a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR) for residents in care. The facility has a mini locked refrigerator for medication and an ice chest for emergency use. The facility has a red sharps container for disposal of syringes. Medication Destruct is done by administrator and staff do it at the facility. Medications were checked for expiration, no labels altered and all medications stored in original containers. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 05/20/2025. 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 in accessible to residents in care. The facility does not have delayed egress. The facility does have residents with oxygen and required signs are posted. The facility does have 5 residents on hospice services. Hospice care plans are kept on file and up to date when a resident is on hospice services. The facility does currently have 3 residents on Home Health services. Home Health services records are kept on file if a resident is on services. The facility entry door is locked to enter only, anyone can exit at all times. Entry and exit doors and gate are alarmed. The courtyard has a gate that is locked to enter but is unlocked to leave trough at any time. LPA conducted interviews with 2 Staff and 3 Residents. Exit interview conducted, no deficiencies cited, copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Mar 27, 2026

Type of visit: Required - 1 Year

At 11:15am on 01/27/2025, Licensing Program Analyst (LPA) Jeffries arrived at the facility, unannounced to conduct an annual inspection. LPA met with facility Administrator Garrett Haner-Tomasko announced the reason for the visit. Administrator and LPA conducted a walking tour of the entire facility. The facility has 14 single resident bedrooms all with bathrooms within all 14 of the rooms. The facility has a kitchen, dining area and 4 common areas separated of two wings of the facility. The facility has a large courtyard with ample shade and seating to accommodate residents and their visitors that foster group activities, leisure time and visits. Fire alarms are hard wired throughout the facility and serviced by Great Western Alarm annually, their last inspection was completed on 12/24/2024. LPA observed at least 2 days on perishable foods and at least 7 days of perishable foods. LPA noted that the facility water temperature was tested throughout the facility and was with in regulation limits. LPA noted that all rooms and bathrooms maintained within regulations standards. LPA observed and noted that all required postings were posted in a prominent location in the facilities front entrance to the left and right of the entrance. LPA noted that all hazardous materials were locked. LPA noted that there are two medication carts is locked and located in locked closets on different wings of the facility. LPA conducted a sample medication audit and found no issues, deficiencies or violations during sample medication audit. LPA noted that all rooms, restrooms, common areas, and outside areas were clean and free of hazards. LPA noted that the facility is clean and in good repair. During this annual inspection walk through LPA noted that this annual inspection was free of violations and citations. Administrator and LPA reviewed all modules of the annual inspection care tools. During the review of the annual inspection care tools there were no violations or citations issued. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Jan 27, 2025

Type of visit: Prelicensing

At 11:30am Licensing Program Analyst (LPA) Jeffries arrived announced to the facility to conduct a pre-licensing facility inspection. LPA met with facility administrator Garrett Haner-Tomasko announced who he is and the reason for the visit. This facility is located adjacent to downtown Paso Robles. At 11:45am Administrator and LPA conducted a walking tour of the entire facility. The facility has 14 single resident bedrooms all with bathrooms within all 14 of the rooms. The facility has a kitchen, dining area and 4 common areas separated of two wings of the facility. The facility has a large courtyard with ample shade and seating to accommodated residents and their visitors and foster social distancing during activities, leisure time and visits. Fire alarms are hard wired throughout the facility and serviced by Great Western Alarm annually, their last inspection was completed on 11/01/2023. Mid Coast Fire Protection tested the pressured sprinkler system on 02/15/2024 LPA observed at least 2 days on perishable foods and at least 7 days of perishable foods. LPA noted that the facility water temperature was tested throughout the facility and was with in regulation limits. LPA noted that all rooms and bathrooms maintained within regulations standards. LPA observed and noted that all required postings were posted in a prominent location in the facilities front entrance and right of the entrance. LPA noted that all hazardous materials were locked. LPA noted that there are two medication carts is locked and located in locked closets on different wings of the facility. Administrator and LPA conducted a full review of the pre licensing care tools modules. LPA noted no technical, violations, or citations issued as a result of the full pre-licensing tools modules review. LPA noted that no other technical, violation, or citation were noted on the full review of the pre licensing care tools review and no violations or citations were issued a result of the facility walk through inspection. Administrators and new licensee have recently conducted the COMP III requirements and a LIC812 has been created to forego the COMP III class, as it has previously been administered Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Mar 8, 2024

Type of visit: Office

COMP II by CAB successfully completed Method: Phone Call at CAB Census (if any clients in care): Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Feb 14, 2024