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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800728
Report Date: 04/11/2024
Date Signed: 04/11/2024 10:32:44 AM

Document Has Been Signed on 04/11/2024 10:32 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:DERRICK FAMILY HOMEFACILITY NUMBER:
405800728
ADMINISTRATOR/
DIRECTOR:
DONNA DERRICKFACILITY TYPE:
735
ADDRESS:9395 HUER HUERO ROADTELEPHONE:
(805) 438-4513
CITY:CRESTONSTATE: CAZIP CODE:
93432
CAPACITY: 2CENSUS: 2DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:53 AM
MET WITH:Licensee, Rob Derrrick TIME VISIT/
INSPECTION COMPLETED:
10:54 AM
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At 7:45am on 04/11/2024, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct an annual facility inspection. LPA met with Licensee Rob Derrick and announced who he is and the reason for the visit.

Licensee and LPA conducted a full tour of the facility. This facility is located in a rural area on 30 acers with two licensed facilities on the property. This facility 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 33 years and as long as 35 years respectively, for each client. with this provider at this address. LPA reviewed client and staff files. LPA reviewed Centrally Stored Medication Records. 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. LPA noted that the smoke alarms were functioning, and a carbon monoxide detector was functioning. 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 full tour of the facility. LPA notes that there were no citations technical, or violations, issued during this annual infection control physical inspection.

Licensee and LPA conducted a full review of the annual control tools. LPA noted that no technical, violations or citations were issued as a result of the full annual care tools and the faculty physical inspection. LPA noted that the facility has been licensed at this location for 22 years and residents have resided at this location for more then 3 decades.

Exit interview, report signed, and report emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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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