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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800130
Report Date: 03/29/2022
Date Signed: 03/29/2022 12:32:02 PM

Document Has Been Signed on 03/29/2022 12:32 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:C.A.L.L.-RAMONA HOUSEFACILITY NUMBER:
405800130
ADMINISTRATOR:JAMI WESTFACILITY TYPE:
735
ADDRESS:3355 RAMONA ROADTELEPHONE:
(805) 466-2909
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 4CENSUS: 4DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Jami West, AdministratorTIME COMPLETED:
12:45 PM
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On 3/29/22 at 11:40 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Administrator Jami West and explained the purpose of the visit.

LPA toured the facility with the administrator and observed the following: The facility has infection control signage at the front door and signage throughout the facility on handwashing, cough etiquette and use of masks. Upon entry to the facility, LPA was screened. Staff are wearing masks properly. The facility has soap and hand sanitizing dispensers and paper towel dispensers in resident bathrooms (2). Fire extinguishers are located in the dining room and garage/medication room and are fully charged and were inspected on 11/08/21. Staff are tested for COVID-19 during the hiring process, and residents are COVID-19 tested prior to admission.

At 12:01 pm, LPA conducted the Infection Control mitigation module with the administrator. No deficiencies cited.

Exit interview conducted and report emailed to the administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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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