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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800728
Report Date: 02/17/2023
Date Signed: 03/09/2023 12:03:26 PM

Document Has Been Signed on 03/09/2023 12:03 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 HOMEFACILITY NUMBER:
405800728
ADMINISTRATOR:DONNA DERRICKFACILITY TYPE:
735
ADDRESS:9395 HUER HUERO ROADTELEPHONE:
(805) 438-4513
CITY:CRESTONSTATE: CAZIP CODE:
93432
CAPACITY: 2CENSUS: 2DATE:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:15 AM
MET WITH:Rob Derrick / LicenseeTIME COMPLETED:
10:15 AM
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 At 7:45am on 02/17/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct an annual infection control inspection. LPA met with Licensee Rob Derrick and announce who he was and the reason for the visit. LPA conduct the annual, infection control inspection.

Licensee and LPA conducted the infection control module of the annual inspection tool. LPA noted that there were no violations of the annual infection control module. LPA noted that there were no violations, technical, or citation issued as a result of the infection control module. Additionally, Licensee and LPA discussed the most current Provider Information Notice [(PIN)23-02] and keeping up with regulations and best practice operations as advised by currently applicable PIN's.

Licensee and LPA conducted a cursory tour of the facility. This is a 4 bedroom, living room, bathroom, kitchen and dining nook area. Two bedrooms are at single occupancy for each client. LPA must note that the clients in this home have been residents for 32 years and as long as 34 years respectively, for each client. with this provider at this address. Facility located in a rural setting. Emergency numbers and postings are posted in the kitchen hallway area. 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 did not observe any noticeable violations technical, or citations during the cursory tour of the facility. LPA notes that there were no citations technical, or violations, issued during this annual infection control inspection.

Exit interview, report signed, and report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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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