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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606316
Report Date: 06/14/2022
Date Signed: 06/14/2022 12:54:06 PM

Document Has Been Signed on 06/14/2022 12:54 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ROBERTS RESIDENTIAL CARE SATELLITE IIIFACILITY NUMBER:
197606316
ADMINISTRATOR:KIMBERLY ROBINSONFACILITY TYPE:
735
ADDRESS:12953 DRONFIELD AVENUETELEPHONE:
(818) 362-5941
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 6CENSUS: 6DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Niecola RobertsTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived to the facility to attempt to conduct the annual infection control visit. Upon arrival, LPA knocked on the door and spoke to the staff Eric, who informed LPA the facility is currently under a COVID outbreak with (5) positive asymotomatic clients (1) client that is exposed and (1) positive staff. Staff Eric, contacted Licensee Niecola Roberts, who LPA had a conversation with via cellphone. The Licensee arrived to the facility and provided additional information regarding the mitigation plan. Licensee informed LPA that she submitted the report. LPA requested for Licensee to submit the new inspection plan that is due by June 30, 2022, according to departmental requirements.

Currently all (6) residents and (7) staff are vaccinated and have booster shots. Facility conducts daily temperature checks for staff and residents. Currently the visiting policy is out doors, and temperature checks are conducted daily for visitors. Daily and disinfecting is done daily. PPE supply is sufficient and the facility has plenty of supplies. Licensee requested more COVID test kits. LPA will check regarding if there are more available.

The facility has (5) bedrooms, and (2) shared, and (3) private. Currently all clients are isolating in there rooms, and there is (1) designated staff that is handling the outbreak.

COVID testing is conducted weekly. Licensee will follow up with LPA regarding the status of clients and staff.

Exit interview conducted with the Licensee
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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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