<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800830
Report Date: 01/17/2023
Date Signed: 01/17/2023 12:35:34 PM

Document Has Been Signed on 01/17/2023 12:35 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 HOMEFACILITY NUMBER:
405800830
ADMINISTRATOR:LIXIA ZHANGFACILITY TYPE:
735
ADDRESS:1240 EL CAMINO REALTELEPHONE:
(805) 466-9029
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 38CENSUS: 35DATE:
01/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Lisa Zhang, Licensee/AdministratorTIME COMPLETED:
12:50 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
On 1/17/23 at 10:45 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced annual infection control inspection of the facility above. LPA met with Lisa Zhang, Licensee/Administrator, and explained the reason for the visit.

LPA toured the facility with the licensee and observed the following: LPA was screened upon entry to the facility. All staff are wearing masks. The facility has infection control signage. The facility has soap in resident bathrooms, however, the bathrooms do not have paper towels and are equipped with hand dryers. Licensee states that some residents place paper towels in the toilet and plug the toilets. LPA directed licensee to change out the hand dryers or find an alternate solution such as staff providing residents with a small quantity of paper towels at each use. Licensee will send photos of hand dryers disconnected or removed and send a written procedure on the new process for dispensing paper towels and send to CCL by 1/24/23. Fire extinguishers are located in the lobby, near Room 3, near Room 18, and in the kitchen. The extinguishers are fully charged and were inspected on 11/3/22 in the lobby and 2/14/22 in all other areas.

At 11:46 am, LPA conducted the Infection Control mitigation module with the licensee. No deficiencies cited.

Exit interview conducted and the report emailed to the licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1