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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801348
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:39:58 PM

Document Has Been Signed on 10/11/2022 03:39 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:KEEFE'S KOTTAGEFACILITY NUMBER:
405801348
ADMINISTRATOR:DAVID KEEFEFACILITY TYPE:
735
ADDRESS:10320 EL CAMINO REALTELEPHONE:
(805) 466-1247
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 6CENSUS: 5DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:David Keefe, Licensee/AdministratorTIME COMPLETED:
03:23 PM
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On 10/11/22 at 1:28 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Mary Keefe, Caregiver, and explained the purpose of the visit. At 2:00 pm, David Keefe, Licensee/Administrator arrived at the facility, and LPA explained the purpose of the visit.

LPA toured the facility with the caregiver until the licensee arrived upon which LPA and licensee toured the facility. LPA observed the following: The facility has infection control signage at the front door and signage throughout the facility on cough etiquette, handwashing, and use of masks. Upon entry to the facility, LPA’s temperature was taken, however, LPA was not asked to sign-in. Licensee will create a visitor sign-in sheet and take a photo or send a copy to LPA by 10/12/22. Licensee will review CDSS Provider Information Notices (PINs) regarding visitation policies and submit a statement that these have been discussed with all staff by 10/15/22. Staff are wearing masks. The facility has soap and paper towels in resident bathrooms (2). Fire extinguishers (2) are located in the entryway and hallway near resident rooms. The extinguishers are fully charged and were inspected on 1/05/22. LPA observed food in the refrigerators (2) and pantry. There is an adequate supply of non-perishable items, however, it did not appear there was an adequate supply of perishable food. Caregiver states that there is plenty of food and referenced the freezer food, however, it is questionable whether the food in the freezers was perishable. Caregiver states that they were going to the grocery store this afternoon. Licensee will take a photo of the food purchased today in the refrigerator and send photo to LPA by 10/12/22. The front gate, approximately three feet high, near the entrance of the facility was locked. LPA was unable to get to the front door. Licensee removed the lock during LPA’s visit. LPA instructed licensee to ensure residents are able to easily access all entry/exit ways.

At 2:15 pm, LPA conducted the Infection Control mitigation module with the licensee. No deficiencies cited.

Exit interview conducted and report emailed to the licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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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