405801815-10-23-2024-29-AS-MRAN-DABRU6-20241023131925

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801815
Report Date: 10/23/2024
Date Signed: 10/23/2024 01:19:30 PM

Document Has Been Signed on 10/23/2024 01:19 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BOB & CORKY'S CARE HOME II		FACILITY NUMBER:	405801815
ADMINISTRATOR:	JOEL WOBROCK		FACILITY TYPE:	740
ADDRESS:	2437 GERDA STREET		TELEPHONE:	(805) 400-0506
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	5	CENSUS: 4	DATE:	10/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:29 AM
MET WITH:			TIME COMPLETED:	10:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rankin arrived at 10:29 am to conduct a 1-year annual visit to the facility above. LPA met with Administrator Joel Wobrock and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environmental Safety: All require postings were posted in the common area of the facility. The facility has 3 resident bedrooms and 2 resident bathrooms currently occupying 4 residents and employs 9 staff. The facility is clean, safe, and sanitary. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The showers have non-skid floors. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents are locked under the kitchen sink, in the laundry room and locked hall closet. The facility has sufficient space inside and outside for activities and visiting. Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 04/19/2025. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BOB & CORKY'S CARE HOME II	FACILITY NUMBER: 405801815
	VISIT DATE: 10/23/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Personnel Records & Training: The facility employes 7 full time staff and 2 administrators. Staff records are kept confidential. LPA reviewed 5 staff files. Files reviewed had current 1st Aid/CPR certifications, all other required documents were reviewed. Administrator Certificate expires 11/21/2024. Annual training of 20 plus hours were documented and complete. Staff handling medications had annual medication training of 8 hours.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four (4) files were reviewed for required documents. All documents including annual appraisals and current Physician records were filed. The facility does not handle cash resources for any of the residents in care.

Food Service: The facility kitchen is clean, safe, and sanitary. The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. Food, snacks, and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies.

Incidental Medical Services: Facility provides or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). Medications for all resident in care are centrally stored. LPA reviewed medications and records. No medication labels were altered, and medications were checked for expiration dates. Medication is given as prescribed with physician’s orders which are kept with the resident’s records.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. Emergency telephone numbers were posted. Facility has emergency food and water supply.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, and cleaners were locked or in accessible to residents in care. The facility does have 1 resident currently using oxygen. The oxygen sign is posted. The facility currently has 1 resident receiving hospice services. Hospice care plans are kept on file and up to date. The facility does not have any delayed egress. There are no bodies of water on the premises.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2