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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801832
Report Date: 01/18/2024
Date Signed: 01/18/2024 01:51:49 PM

Document Has Been Signed on 01/18/2024 01:51 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:WILCOX'S MESA HOMEFACILITY NUMBER:
405801832
ADMINISTRATOR:BRANDEE CHURCHFACILITY TYPE:
735
ADDRESS:711 RIDGE ROADTELEPHONE:
(805) 929-3118
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 4CENSUS: 4DATE:
01/18/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Stephen Wilcox, LicenseeTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) De Leon conducted a Case Management Visit to do a welfare check on the residents in care. LPA was joined by TCRC QA Miguel Magana. LPA met with the Licensee and explained the purpose of the visit.

The residents were clean and safe on arrival. The facility has food, medications, and all needed supplies for the facility to run properly. Resident 1 (R1's) family was present and had no issues with safety concerns. Licensee is present at the facility and the facility is currently employing 4 staff. Administrator is on leave and Licensee is covering the duties of Administrator at this time. Staff 1 (S1) is currently in process of taking all required courses to become an Administrator. Licensee is going to speak with another Administrator to take on the duties temporarily till the new Administrator is certified.

The facility property is not currently up for sale. The Licensee and POA are not planning to list the facility up for sale at this time. The Licensee has agreed when and if it is decided at a later date to list the property for sale Community Care Licensing (CCL) and Tri-County Regional Center would be notified. The Licensee will work with both agencies and provide a full closure plan with relocation. Licensee agreed the facility will remain open and operating until any placement's are resolved.

LPA requested the following documentation for review: 4 residents LIC 602 Physicians Reports, Appraisal needs and services plan, and Identification and emergency forms. S1 provided most of the forms at the visit and S1 will email LPA the remaining documents requested.

Exit interview conducted and copy of report printed for Licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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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