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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800577
Report Date: 08/04/2022
Date Signed: 08/04/2022 04:02:32 PM


Document Has Been Signed on 08/04/2022 04:02 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: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: 43DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:54 PM
MET WITH:Kirk Klotthor, Executive Director/AdministratorTIME COMPLETED:
03:33 PM
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On 8/04/22 at 1:54 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Administrator Kirk Klotthor 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. The facility has soap and paper towels in resident bathrooms. The fire extinguishers (11) are located in the offices’ hallway, common area hall, kitchen (2), laundry room, and (2) in each of the three neighborhoods. The extinguishers are fully charged and were inspected on 6/2/22. Maintenance staff attempted to test the carbon monoxide detectors, however, the alarm did not sound. Administrator will follow-up with Alpha Fire to determine the most recent date the detectors were tested. Administrator will send documentation to this affect on or before 8/11/22 to LPA.

At 2:40 pm, LPA conducted the Infection Control mitigation module with the administrator. No deficiencies cited.

Exit interview conducted and report emailed to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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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