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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801621
Report Date: 12/19/2022
Date Signed: 02/02/2023 03:01:29 PM

Document Has Been Signed on 02/02/2023 03:01 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: DATE:
12/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Lote Rouse / Program CoordinatorTIME COMPLETED:
11:04 AM
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At 9:00am on 12/19/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct the annual infection control inspection. LPA met with Program Coordinator Lote Rouse (S1), Kayla Walker (S2) and announced who he was and the reason for the visit.

At 9:33am, S1 and LPA conducted a cursory tour of the facility. This Day Program has a main lobby, conference room, nine classrooms, kitchen, two storage rooms and two bathrooms. Medications are locked in a cabinet in the kitchen toward the back of the facility kitchen. Lunches are brought from home by the clients and assisted as need by staff as needed. There is a supply of food and snacks on hand for clients who did not come to the program with lunch. LPA noted that all classrooms were clean and free of hazards and no obstructions to exits. Alpha Fire conducted the annual fire inspection for the facility on 12/16/2022. LPA noted that there is an Administration office attached to the facility on the north side of the facility and and occupational program on the south side of the facility, both administration and occupational program have inside access to the facility. Central entry point to the facility is the front door of the facility where screening is conducted. LAP did not note any visible violations on the cursory tour and no citations were issued on the cursory tour of the facility.

At 9:45am S1, S2 and Administrator Tarci Hollinger, conducted the annual infection control portion of the annual inspection. LPA noted that there were no violations cited during the annual infection control module of the annual inspection. No citations issued at this time.

Exit interview, report signed and report email.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2022
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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