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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 401700013
Report Date: 11/29/2021
Date Signed: 11/29/2021 04:20:33 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: DATE:
11/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Chris Wohlwend, AdministratorTIME COMPLETED:
12:45 PM
NARRATIVE
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On 11/29/21 at 12:02 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced case management visit. The purpose of this visit is to issue a deficiency identified during the course of communication with the facility regarding a resident’s transfer into the facility.

On 11/07/21, Administrator informed LPA of Resident #1 (R1) being accepted to the facility on or before 11/02/21.

On 11/16/21 at 3:03 pm, LPA contacted Administrator to determine the diagnosis of R1. Administrator provided a copy of R1’s Physician’s Report which shows a primary diagnosis of Dementia. LPA reminded the Administrator that the facility is not licensed for dementia residents and that administrator would need to provide the resident with a written 30-day notice of eviction. Administrator agreed.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency is observed and cited (Refer to LIC 809-D).



Exit interview conducted, Appeal Rights provided, and a copy of the report issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATASCADERO CHRISTIAN HOME
FACILITY NUMBER: 401700013
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2021
Section Cited

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87208(c) Plan of Operation - (c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b).

This requirement is not met as evidenced by:
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Based on interviews, the licensee did not comply with the section cited above, as a dementia resident was accepted to the facility and the facility is not licensed for dementia residents. This poses a potential health and safety risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2021
LIC809 (FAS) - (06/04)
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