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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425203
Report Date: 09/19/2022
Date Signed: 04/11/2023 01:03:32 PM

Document Has Been Signed on 04/11/2023 01:03 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:MCCOLLUM'S HOPE RANCHFACILITY NUMBER:
366425203
ADMINISTRATOR:GOUCHER, KATHYFACILITY TYPE:
735
ADDRESS:589 FERN DRIVETELEPHONE:
(909) 336-9710
CITY:TWIN PEAKSSTATE: CAZIP CODE:
92391
CAPACITY: 6CENSUS: 3DATE:
09/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Kathy Goucher, AdministratorTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to conduct a required annual inspection with an emphasis on infection control. LPA identified herself to Administrator Kathy Goucher. Staff verified that the facility currently has no active and/or suspected COVID-19 cases.

During the inspection, LPA Bueno and Administrator Goucher toured the facility inside and out. LPA Bueno interviewed care staff regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases and that staff are trained in the facility's infection control measures. The facility continuously updates their COVID-19 mitigation plan.

LPA Bueno observed that the facility appeared to be meeting operational requirements. LPA observed that all utilities and appliances were functioning properly and all passageways clear of obstruction, including emergency exits. The facility was equipped with sufficient food supply and emergency supplies. All areas of the facility, including client bedrooms and restrooms, appeared clean and in good repair. Fire extinguishers were last checked in July 2022 and combination smoke detector and fire alarm were functioning.

LPA did not observe a visitor sign in sheet and a technical advisory is being issued. An exit interview was conducted where this report was discussed, and a copy of this report was provided to administrator at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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