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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800117
Report Date: 12/08/2022
Date Signed: 12/08/2022 03:24:47 PM

Document Has Been Signed on 12/08/2022 03:24 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:DERRICK FAMILY HOME #2FACILITY NUMBER:
405800117
ADMINISTRATOR:DONNA DERRICK 98FACILITY TYPE:
735
ADDRESS:9415 HUER HUERO ROADTELEPHONE:
(805) 438-4331
CITY:CRESTONSTATE: CAZIP CODE:
93432
CAPACITY: 6CENSUS: 4DATE:
12/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Rob Derrick/Ad AdministratorTIME COMPLETED:
12:00 PM
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At 9:00am on 12/08/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct an annual infection control inspection. At the time of arrival the facility Licensee, Donna Derrick was not present. LPA observed Administrator for Derrick Family Home #1(405800728) on the property and announce who he was and the reason for the visit. LPA requested that they conduct the annual infection control inspection of Derrick Family Home #2. Rob Derrick was able to gain access of the facility and LPA and Mr. Derrick conducted the annual infection control inspection.
At 9:15am Mr. Derrick and LPA conducted the infection control module of the annual inspection tool. LPA noted that there were no violations of the annual infection control module. At 9:50am Mr. Derrick and LPA conducted a cursory tour of the facility. This is a 3 bedroom, living room, bathroom, kitchen and dining nook area. Two bedroom are at double occupancy for 4 clients. LPA must note that the clients in this home have been residents as short as 34 years and as long as 44 years with this provider at this address. Facility located in a rural setting. Emergency numbers and postings are posted in the kitchen hallway area. LPA observed more than two days of perishable and more than seven days of non-perishable food. A written disaster and mass casualty plan is readily available located on the facility hallway wall. LPA did not observe any noticeable violations during the cursory tour of the facility. LPA notes that there were no citations issued during this annual infection control inspection.

Exit interview, report signed, and report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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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