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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800577
Report Date: 06/28/2021
Date Signed: 06/28/2021 04:21:09 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:VILLAGE AT SYDNEY CREEK, THEFACILITY NUMBER:
405800577
ADMINISTRATOR:KIRK P KLOTTHORFACILITY TYPE:
740
ADDRESS:1234 LAUREL LANETELEPHONE:
(805) 543-2350
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:84CENSUS: DATE:
06/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:24 AM
MET WITH:Kirk Klotthor, AdministratorTIME COMPLETED:
02:30 PM
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At 11:24 am, on 06/28/2021, Licensing Program Analysts (LPAs) Darlene Chavez and Toan Luong conducted an unannounced annual infection control inspection of the facility above. LPAs informed administrator of the reason for the visit. LPAs, administrator, and wellness coordinator toured the facility. LPAs' initial tour of the facility resulted in observations which were immediately addressed by the administrator and facility staff: At 11:31 am, LPA requested the facility screen LPAs for COVID-19 upon entry to facility which was immediately conducted. At 11:35 am, the current 8.5"x11" complaint poster was observed, and administrator will post a 20"x26" immediately. At 12:08 pm, administrator will place COVID-19 hand-washing signage in common area bathroom near Neighborhood 3. At 12:21 pm, the kitchen freezer display was observed not functioning. Administrator has requested maintenance to correct.

At 1:20 pm, LPA Chavez conducted the Infection Control mitigation module with administrator. No deficiencies.

Exit interview conducted and report emailed to administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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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