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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800117
Report Date: 12/11/2023
Date Signed: 12/11/2023 02:35:03 PM

Document Has Been Signed on 12/11/2023 02:35 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: 3DATE:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Licensing Donna DerrickTIME COMPLETED:
02:40 PM
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 At 10:00am on 12/11/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility to conduct and unannounced annual inspection LPA met with Licensee Donna Derrick and explained the reason for the visit.
The facility is located in a rural location approximately 30 miles from Templeton and 30 miles from San Luis Obispo, the two closest hospitals. There are local emergency services in this area. The clients in this home have been at this location between 42 to 54 years together.
LPA toured facility with Licensee. The facility is maintained in conformance with state fire marshal regulations. Smoke detectors and carbon monoxide detectors functioning throughout the home. Fire extinguishers are new and were fully charged. Inside and outside passageways are free from obstruction. The inside temperature is a comfortable 70 degrees F and the water temperature was measured within regulation requirements of 105* -120*(f). Residents’ rooms are appropriately furnished with adequate lighting. 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 reviewed centrally stored medication logs.. Medications are stored in a locked box in the kitchen cabinet. There is a signed and dated order from a physician for prescriptions. LPA observed the medication administration record (MAR) and medications are given per physician's orders.

Licensee and LPA conducted a full review of the annual control tools modules. LPA noted that no technical, deficiencies, violations or citations were issued as a result of the annual control module full review. LPA noted that there were no technical, deficiencies, violations or citations were issued as a result of the annual inspection

Exit interview, no deficiencies cited, report given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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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