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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801835
Report Date: 07/24/2024
Date Signed: 07/24/2024 10:24:10 AM

Document Has Been Signed on 07/24/2024 10:24 AM - 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/
DIRECTOR:		AMY LYNN HICKSFACILITY TYPE:
735
ADDRESS:648 LAURA WAYTELEPHONE:
(805) 239-2570
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6CENSUS: 4DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:37 AM
MET WITH:Administrator, Amy HicksTIME VISIT/
INSPECTION COMPLETED:
11:58 AM
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 At 8:37am on 07/24/2024, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conduct the annual inspection. LPA met with Administrator Amy Hicks and announced who he was and the reason for the visit.
Administrator and LPA conducted a physical tour of the facility. LPA noted that for following observations: Smoke detectors and carbon monoxide detectors were tested all functioning correctly throughout the facility. Both fire extinguishers were properly charged in the green range. No obstructions in walkways or entrance/exits were observed. LPA observed at least 2 days of perishable foods and at least 7 days of non-perishable foods. LPA observed all three client bedroom and two client bathrooms. All client bedrooms had appropriate linins, lighting and storage for clients. Both client restrooms had nonskid mats or nonskid tape or floors in showers and all hand railing was stable. LPA observed emergency water stored on back patio and garage and emergency disaster plan was posted in the kitchen. LPA noted that all posting were posted in hallway or kitchen common areas. LPA noted that the facility was in good repair and did not observe any items notable of violation, citation or technical. LPA conducted a sample file review of client and staff files. LPA conducted a sample review of Centrally Stored Medication Records, LPA noted that client PNI is handled through Trust Management Services (TMS) as well as being the payee for Social Security for all clients in care. .

Administrator and LPA conduction a review of each module of the annual inspection tool. LPA noted that there were no citations, violations, or technical noted during the annual inspection module review of the inspection tool. Final result of this annual inspection did not show and violations, citations or technical at this time.
LPA interviewed 1 staff and 1 client. LPA conducted language survey and recorded facility email.

Exit interview, report read, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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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