405800830-1-29-2026-29-AS-RDLN-DQSTSC-20260129135856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800830
Report Date: 01/29/2026
Date Signed: 01/29/2026 01:59:15 PM

Document Has Been Signed on 01/29/2026 01:59 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:	AMERICAN CARE HOME		FACILITY NUMBER:	405800830
ADMINISTRATOR/ DIRECTOR:	LIXIA ZHANG		FACILITY TYPE:	735
ADDRESS:	1240 EL CAMINO REAL		TELEPHONE:	(805) 466-9029
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY: 38		CENSUS: 30	DATE:	01/29/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:15 PM
MET WITH:	Maria Lopez, Back up to Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) De Leon conducted a 1 year annual visit to the facility above. LPA met with Back up Administrator Maria Lopez and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Infection Control Plan to the department. The bathrooms have toilet paper and hand soap. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE) initially upon hire and annually thereafter. Physical Plant & Environmental Safety: The facility is a 19 bedroom with 6 shared resident bathrooms, 4 common area bathrooms and 1 staff bathroom, currently occupying 30 residents and employs 7 staff with 1 Administrator and 2 back ups to the Administrators. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen is clean, safe and sanitary. Toilet, hand washing and bathing facilities are operational. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in storage rooms. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard and courtyard for resident use with plenty of shade. The facility has telephone and internet service for resident use. Water temperatures were tested in resident restrooms at 112.9 F within regulation requirements. Continued 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMERICAN CARE HOME	FACILITY NUMBER: 405800830
	VISIT DATE: 01/29/2026

NARRATIVE

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Operational Requirements: The facility has a current plan of operation with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity 38 Ambulatory of which 2 can be Non-Ambulatory.

Staffing: The facility employes 7 staff and 1 Administrator and 2 back ups. Staff records are kept confidential. LPA reviewed 5 staff files for 1st AID/CPR, Finger print clearances, Applications, and Health exam with TB results.

Personnel Records & Training: The facility keeps confidential files for each staff member. Five staff files were reviewed and had current 1st AID/CPR training, any staff handling medication had annual training. Staff have annual training completed from 2025-2026 for 8 plus hours. The cook has a current food handlers certificate.

Clients Rights: All require postings were posted in the common area of the facility. Personal rights, CCL Complaint poster is posted. The current license along with CCL reports and PIN's were printed in folders for review, and visitation policy is posted at entry. Internet is provided to each client and each client is given confidentiality and privacy.

Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 45 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. A menu is posted for residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices.

Continued 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMERICAN CARE HOME	FACILITY NUMBER: 405800830
	VISIT DATE: 01/29/2026

NARRATIVE

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Clients Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans, TB results, Personal Rights, and Safeguard for personal property and valuables. The Facility does handle cash resources for residents in care. Facility does submit incident reports to the department when required.

Health Related Services: Facility provides Centrally Stored Medications to all residents in care. First Aid is provided to residents in care. Facility assist in providing transportation to medical and dental appointments when needed.

Incidental Medical Services: The facility uses the Medication Administration Record (MAR) and the Centrally Stored Medication and Destruct Record (CSMDR). Residents medication records were reviewed, prescriptions and nonprescription PRN had doctors orders. Medications, PRN medications and Over the counter medications were checked for expiration dates, labels were not altered, all were stored in their original containers and no issues were found.

Disaster Preparedness: The facility has an up to date Disaster Plan posted at the facility. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 01/06/2026. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Emergency Intervention: The facility does not use restraints or seclusion and does not conduct the CPI Non-Violent Crisis Intervention Training.

LPA's conducted interviews with 1 staff and 3 residents.

Exit interview conducted and copy of report printed for Back up Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

LIC809 (FAS) - (06/04)

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