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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800467
Report Date: 04/21/2023
Date Signed: 04/21/2023 10:29:56 AM

Document Has Been Signed on 04/21/2023 10:29 AM - 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:GARDEN CREEKFACILITY NUMBER:
405800467
ADMINISTRATOR:KIRK P KLOTTHORFACILITY TYPE:
740
ADDRESS:73 BROAD STREETTELEPHONE:
(805) 543-2311
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY: 72CENSUS: 57DATE:
04/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Jodie Sweeney / LVNTIME COMPLETED:
10:16 AM
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 At 9:00am on 04/21/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct a health and welfare visit/check addressing the incident report submitted on 04/19/2023, pertaining to Resident 1 (R1). LPA met with facility nurse, Jodie Sweeney, LVN and announced who he was and the reason for the visit.

LPA conducted a abbreviated cursory tour of the facility for observation. LPA was able to observe R1 in the facility. R1 appeared to be in good physical condition and functioning normally in the facility dining room with facility community peers..

LPA requested the following documents:

-Staff schedule and contact phone numbers.
-Resident roster with room numbers and contact information.
-Facility call button summary for 04/18 -19/2023.
(Below documents received by LAP via email)
-R1's Physicians Report, per admissions appraisal, appraisals needs and services plan, and list of current
medications.

LPA will forward observational and documentation information collected and follow up with Licensing Program Manager.

Exit interview, report read, report singed and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2023
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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