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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801495
Report Date: 07/13/2022
Date Signed: 07/13/2022 10:56:57 AM


Document Has Been Signed on 07/13/2022 10:56 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:FOOTHILLS RESIDENTIAL CARE FOR THE ELDERLYFACILITY NUMBER:
405801495
ADMINISTRATOR:JANE QUINESFACILITY TYPE:
740
ADDRESS:696 E. FOOTHILL BLVD.TELEPHONE:
(805) 541-2042
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:6CENSUS: 6DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Licensee/JANE QUINESTIME COMPLETED:
12:34 PM
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 At 10:30am on 07/13/2022, Licensing Program Analyst (LPA) Jeffries, arrived unannounced at the facility to conduct an annual infection control module inspection. LPA met with Licensee Jane Quines and announced who he was as the reason for the visit. LPA was properly screened for COVID-19 protocols at the front door single entry point.

LPA and Licensee took a walking tour of the facility. LPA observed 8 bedrooms, 3 bathrooms, (6 single resident bedrooms and 2 staff bedrooms), a large family room, living room, dining room, kitchen and laundry room. Medication is stored in a locked cart in the living room and staff and resident files, along with hazardous chemicals are stored in a locked closet near the kitchen near the laundry room. LPA observed ample supply of PPE that exceeds 30 days. LPA observed a 7 day supply of non-perishable and 2 day supply of perishable foods for six residents. LPA observed fire extinguishers hardwired through out the facility and two working carbon monoxide detectors. LPA did not see any hazards that warranted a regulation violation during this facility tour.

LPA and Licensee went through the infection control module portion of the annual inspection and found no deficiencies. There were no deficiencies discovered at this time for this annual infection control inspection.


Exit interview, report signed and report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
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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