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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005512
Report Date: 09/29/2022
Date Signed: 09/29/2022 04:27:14 PM

Document Has Been Signed on 09/29/2022 04:27 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BARN LIFEFACILITY NUMBER:
306005512
ADMINISTRATOR:CARVER, MATHEW WILLIAMFACILITY TYPE:
775
ADDRESS:126 E 16TH STTELEPHONE:
(800) 759-1930
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 30CENSUS: 12DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Alyssa Panis - Chief Operating OfficerTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Barn Life. The purpose of today's visit was to conduct a Required 1 Year inspection focusing primarily on Infection Control. LPA Velazquez was allowed entry into the facility and met with Chief Operating Officer (COO) Alyssa Panis and Infection Control Officer (ICO) Kristin Minichiello. The facility is licensed as an Adult Day Program with a capacity for 30 clients. There are no active COVID-19 cases in the facility.

At 3:00 PM LPA Velazquez conducted a tour of the physical plant along with COO Panis. A sign-in area was present in the entry way of the facility and a thermometer was present that is utilized to test temperature. The facility consists of multiple indoor spaces which include therapy, art, and activity rooms. There is a large barn structure in the back of the campus with a client bathroom which did not provide hot water for client use. There is no kitchen utilized for cooking as the facility does not provide cooked meals. There is one client bathroom in another building and LPA measured the water temperature at 115.8 degrees Fahrenheit. There is ample outdoor space on the grounds with seating and shading for client use. Smoke detectors and sprinklers are hardwired and remain intact. Alarm systems are tested through Bay Alarm Company and the Costa Mesa Fire Department and were inspected on 10/27/2021. LPA Velazquez was provided with a copy of the most recent Fire Alarm Inspection Report. Other smoke detectors were tested and found to be in operating condition. The fire extinguishers throughout the facility were fully charged. The reception area had a table with fruit, snacks, and water available for clients. There is also a water dispenser with hot and cold water available for client us. There were lockers present available for client use. A working refrigerator was observed that is available for client use. This day program does not dispense medications and does not handle client money. Toxins and cleaning supplies were located in a locked cabinet in the staff bathroom and are inaccessible to clients. The sharps were located in a locked cabinet in the reception area of the facility and are inaccessible to clients.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BARN LIFE
FACILITY NUMBER: 306005512
VISIT DATE: 09/29/2022
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No resident or staff files were reviewed at the time of this visit as this inspection focused primarily on Infection Control. LPA Velazquez reviewed PIN 22-28-ASC titled Best Practices for Visitation Related to Coronavirus Disease 2019 (COVID-19) and the Rescission of the Statewide Visitation Waiver with COO Panis and ICO Minichiello.


There were no deficiencies issued during this Required 1 Year inspection. An exit interview was conducted with COO Alyssa Panis and a copy of this report was provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC809 (FAS) - (06/04)
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