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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801835
Report Date: 06/28/2022
Date Signed: 06/28/2022 02:23:02 PM

Document Has Been Signed on 06/28/2022 02:23 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:SCHWED ADULT FAMILY HOME IIIFACILITY NUMBER:
405801835
ADMINISTRATOR:DOLLY SCHWEDFACILITY TYPE:
735
ADDRESS:648 LAURA WAYTELEPHONE:
(805) 239-2570
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6CENSUS: 6DATE:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Amy Hicks/House LeadTIME COMPLETED:
01:30 PM
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At 11:25am on 06/28/2022, Licensing Program analyst (LPA) Jeffries arrived at the facility to conduct an annual infection control module inspection. LPA was screened at the front door for temperature and COIVD-19 exposure risk check. LPA met with Amy Hicks, House Lead and announced the reason for the visit.
LPA and house lead went through all area of the infection control module and did not find any deficiencies at this time.
LPA toured facility. The facility is maintained in conformity with State Fire Marshall Regulations. Fire extinguishers are fully charged current on serviced tags. Smoke alarms are hard wired throughout the facility as well as battery operated and are functioning as required. The carbon monoxide detector functioning. Outdoor area was toured, there are appropriate outdoor furnishings and walkways are safe of hazards and areas that provide shade. All walkways are free of obstruction. There is an adequate amount of perishable and nonperishable foods. All foods are stored to prevent microorganism contamination. The facility maintains a comfortable temperature around 74 degrees F (temperature outside on this day during visit was 99*F). There are lamps/lights for each room to ensure safety and comfort for all persons in the facility. There is a first aide kit located in hall way cabinet above the centrally stored and locked medication box. Facility has a written and readily available disaster plan posted by front door and back in dining area. LPA did not observe any deficiencies that warranted a citation during this annual infection control inspection.

Exit interview, report signed, copy emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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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