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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801495
Report Date: 05/19/2023
Date Signed: 05/19/2023 11:13:27 AM


Document Has Been Signed on 05/19/2023 11:13 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:
05/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator / Jane QuinsTIME COMPLETED:
11:45 PM
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 At 9:15am on 05/19/2023. Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual facility inspection. LPA met with Administrator Jane Quines announced who he was and the reason for the visit.
Administrator and LPA conducted a tour of the facility inside and outside. The facility has an out door area with shade and benches for the residents. LPA noted that facility as a full Genreac generator, powered by gas for full power during outages The facility has a large living room another large activity room, large dining room and large kitchen. The facility has six single resident occupancy bedrooms, 3 bathrooms that are shared. All residents rooms have working smoke detectors, proper linin, lighting, and storage for residents. There is a internal sprinkler system that is serviced annual by Alpha Fire. LPA observed smoke detectors that are hard wired in all rooms and two carbon monoxide detectors all in working order. LPA noted that all hallways, passages and doors were not obstructed. The facilities first aide kit is complete, located in the dining room cabinets. There is a locked medication cart in the living room area. There is an additional small refrigerator for medication that requires refrigeration where they use a locking case inside the refrigerator for that type of medication storage. LPA conducted a medication audit and found all medication documents to be in good order. LPA reviewed all staff falls and found all documents to be in good order. LPA reviewed all resident files and found all documents to be complete and in good order. LPA observed at least 7 days of perishable foods and at least 2 days of non perishable foods on hand at the facility. LPA noted that the facility is clean and in good repair. LPA did not discover any violations, citations, or technical during the facility physical tour.
Administrator and LPA reviewed all modules of the annual inspection. LPA found no citations, violations, or technical during the review of all the modules of the annual inspection. LPA noted at this time there are no citations, violations or technical issued as a result of this annual facility inspection.

Exit interview, report read, report singed and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
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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