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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801621
Report Date: 02/16/2022
Date Signed: 02/16/2022 03:20:20 PM

Document Has Been Signed on 02/16/2022 03:20 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:NCI AFFILIATES, INC-LINNEFACILITY NUMBER:
405801621
ADMINISTRATOR:TRACI M HOLLINGERFACILITY TYPE:
775
ADDRESS:496 LINNE ROADTELEPHONE:
(805) 238-6630
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 75CENSUS: 51DATE:
02/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Lote Rouse, Program Coordinator and Traci HollingerTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Olson and Chavez conducted an on-site 1 year infection control annual visit to the facility above on 02/16/2022 at 2:10 PM. LPAs met with Administrator Traci Hollinger and Lote Rouse, Program Coordinator and explained the purpose of the visit.

LPAs took a physical plant tour of the inside and outside of the facility with staff.
The facility has an entry point at the front door where everyone entering completes sign-in and temperature check for all staff and visitors wanting to come into the facility. All documentation is kept in on file.

The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. The safety coordinator George Bradley is in charge of infection control and provides training and education to staff, clients and visitors.

If any suspected or confirmed cases of Covid-19 are found inside or outside the facility a staff will use PPE supplies that will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. The facility has proper cleaning and disinfectant policies. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies.
Continued on 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NCI AFFILIATES, INC-LINNE
FACILITY NUMBER: 405801621
VISIT DATE: 02/16/2022
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Fire extinguishers are charged and inspected annually. Smoke alarms and Carbon monoxide detectors are present.
No deficiencies observed during the visit and all infection control protocols are implemented and are being followed.
Exit interview completed and copy of report emailed to Administrator/Licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
LIC809 (FAS) - (06/04)
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