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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801612
Report Date: 07/26/2022
Date Signed: 07/27/2022 05:40:42 AM


Document Has Been Signed on 07/27/2022 05:40 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:MISSION LODGEFACILITY NUMBER:
405801612
ADMINISTRATOR:KATHLEEN TUCKERFACILITY TYPE:
740
ADDRESS:5253 MONTEREY ROADTELEPHONE:
(805) 226-7431
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:15CENSUS: 10DATE:
07/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Garrett Haner/AdministratorTIME COMPLETED:
10:45 AM
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 At 8:30am on 07/26/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility to conduct a case management visit pertaining to a facility reported incident of alleged staff misconduct. LPA met with Administrator Garrett Haner and announced the reason for the visit.
Administrator and LPA reviewed common area video that has a clear view of Resident 1's (R1) room. Administrator and LPA reviewed morning routine for transitioning R1 from room to daily activities and breakfast in the common area of the facility. LPA noted that the on 07/18/22 Staff 3 and 4 (S3, S4) took a total of approximately 9 minutes from entering the threshold door of R1's room to bringing R1 out to the common area. LPA noted that on 07/20/22 that S2 took approximately 13 minutes to transition R1 from their room to common area. And on 07/22/22 it took S1 12 minutes and 21 seconds to transition R1 from their room to the common area. LPA noted that R1's shower schedule was not on the days observed in the video recordings. LPA noted that R1 facial expressions was smiling and consistently the same on all 3 days observed during their transition to the common area. LPA conducted interviews, collected documentation and requested documentation. LPA observed R1 at 9:30am on 07/26/22 in the common area smiling with same expression consistent with each day observed from the video recordings. At this time LPA observed that the health and welfare of R1 to in good care.

Exit interview, report singed, and report emailed.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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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