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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801098
Report Date: 07/20/2022
Date Signed: 07/20/2022 11:32:44 AM

Document Has Been Signed on 07/20/2022 11:32 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:ADULT TRANSITIONAL PROGRAMFACILITY NUMBER:
405801098
ADMINISTRATOR:THOMAS QUINTANAFACILITY TYPE:
772
ADDRESS:1511 OSOS STREETTELEPHONE:
(805) 541-0107
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 12CENSUS: 9DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Thomas Quintana, Program Manager/AdministratorTIME COMPLETED:
11:50 AM
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On 7/20/22 at 10:35 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Program Manager Thomas Quintana and explained the purpose of the visit.

LPA toured the facility with the program manager 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, hand sanitizer, and paper towels in resident bathrooms. The fire extinguishers (4) are located upstairs in the hallway and downstairs in the back hallway, the living room area, and the office. The extinguishers are fully charged and were inspected on 11/8/21. There are currently six residents who have tested COVID-19 positive and are in isolation. There are two bathrooms dedicated to the COVID-19 positive residents and three bathroom dedicated to the residents without COVID-19.

At 11:00 am, LPA conducted the Infection Control mitigation module with the program manager. No deficiencies cited.

Exit interview conducted and report emailed to the program manager.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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