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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801720
Report Date: 02/16/2023
Date Signed: 02/16/2023 01:16:30 PM


Document Has Been Signed on 02/16/2023 01:16 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: 2DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Michelle Marcos, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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On 2/16/23 at 11:30 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Administrator Michelle Marcos and explained the purpose of the visit. Administrator had a personal errand and states she will return shortly. At 12:16 pm, administrator was unable to return and LPA met with Desiree Verry, Administrator.

LPA toured the facility with Staff #1 (S1) and observed the following: The facility is missing signage at the front door regarding the visitor policy. Licensee will post the policy, take a photo, and send to LPA by 2/17/23. LPA was screened upon entry. The facility has hand sanitizer in key locations throughout the facility. Resident bathrooms’ (2) are stocked with soap and paper towels. Between 11:55 am and 11:58 am, the water temperatures in resident bathrooms were tested and recorded at 131.3F degrees (front bathroom) and 130.3F degrees (bathroom in back bedroom). Water temperatures are not in compliance of the regulatory 105F to 120F degrees. Deficiency cited. 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 6/05/22. External gates (2) leading to/from the backyard are not self-closing. Licensee will adjust the gates to ensure they auto-close, send videos of the gates self-closing, and send to LPA by 2/23/23. Sprinkler heads are leaking and running over the walkway outside. Leaves and dirt add to the safety of the surface. Licensee will fix the leak, take a photo, and send to LPA by 2/23/23.

At 12:37 pm, LPA conducted the Infection Control mitigation module with administrator Michelle Marcos.

Exit interview conducted, deficiency cited and the report and appeal rights given to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
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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Document Has Been Signed on 02/16/2023 01:16 PM - It Cannot Be Edited

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: RESIDENCE, THE
FACILITY NUMBER: 405801720

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303(e)(2) Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on testing, the licensee did not comply with the section cited above in two resident bathrooms whose water temperatures were recorded at 131.3F degrees and 130.3F degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
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Licensee will adjust the water temperatures to comply with the regulation, take videos of the temperatures in each bathroom and send videos to LPA by end of day 2/17/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
LIC809 (FAS) - (06/04)
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