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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 401700013
Report Date: 05/14/2021
Date Signed: 05/14/2021 12:26:43 PM

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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ATASCADERO CHRISTIAN HOMEFACILITY NUMBER:
401700013
ADMINISTRATOR:CHRIS WOHLWENDFACILITY TYPE:
740
ADDRESS:8455 SANTA ROSA ROADTELEPHONE:
(805) 466-0281
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:64CENSUS: 38DATE:
05/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Chris Wohlend/AdministratorTIME COMPLETED:
01:00 PM
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At 9:00am, on 05/14/2021, Licensing Program Analysts(LPAs) Darlene Chavez and Mark Jeffries conducted an unannounced annual inspection of the facility above. LPAs and administrator toured the facility. LPAs initial tour of the facility resulted in the following observations which were immediately addressed by the administrator and facility staff:

-At 10:00 am, oxygen sign was added to resident room #67.
-At 10:05 am, stair rail was repaired by maintenance personnel.
-At 10:15 am, facility staff secured storage room near laundry area, outdoor walk-in refrigerator, gates (2) in laundry area, and building storage rooms (2).
-At 11:55 am, loose paint was removed from common area.
-At 12:10 pm,,bent metal siding was repaired.

At 11:15 am, LPA Chavez conducted Infection Control mitigation module with administrator. Administrator was instructed to immediately search for an N95 fit testing vendor. No other corrections found in mitigation module..

Exit interview conducted and report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021
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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