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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801720
Report Date: 03/01/2022
Date Signed: 03/01/2022 07:08:25 PM


Document Has Been Signed on 03/01/2022 07:08 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:RESIDENCE, THEFACILITY NUMBER:
405801720
ADMINISTRATOR:MICHELLE MARCOSFACILITY TYPE:
740
ADDRESS:3220 CALLE MALVATELEPHONE:
(805) 596-0812
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:6CENSUS: 4DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Meynard Marcos, LicenseeTIME COMPLETED:
06:00 PM
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On 3/01/22 at 4:45 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Licensee/Administrator Meynard Marcos and explained the purpose of the visit.

LPA toured the facility with licensee and observed the following: The facility has signage at the front door regarding the visitor policy. When licensee arrived, LPA was screened. The facility has hand sanitizer in key locations throughout the facility. Kitchen and resident bathrooms’ (2) sinks are stocked with soap, and bathrooms have paper towels. The facility has signage for COVID infection control measures including cough etiquette and handwashing reminders. A fire extinguisher is located next the entrance to the garage from the house and is fully charged and purchased on 6/05/2021.

At 5:01 pm, LPA conducted the Infection Control mitigation module with the licensee. No deficiencies cited.

Exit interview conducted and report emailed to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
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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