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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801854
Report Date: 01/11/2024
Date Signed: 01/11/2024 10:18:12 AM

Document Has Been Signed on 01/11/2024 10:18 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:CAPSLO ADULT DAY CENTERFACILITY NUMBER:
405801854
ADMINISTRATOR:MARA WHITTENFACILITY TYPE:
775
ADDRESS:1345 OAK STREETTELEPHONE:
(805) 239-5679
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 25CENSUS: 14DATE:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Site Supervisor - Lydia HuntTIME COMPLETED:
10:29 AM
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At 8:30am on 01/11/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual facility inspection. LPA met with Site Supervisor Lydia Hunt (S1), Administrator Mara Whitten was emailed of the annual inspection and was not present during this annual inspection.

LPA conducted a psychical inspection, LPA noted that the church next to the facility had a active construction zone that was separated by yellow tape caution tape. LPA observed clients had no issue navigating the ramp entrance and exit to the facility. This Day Program has 4 group rooms, a kitchen and dining room area, two bathrooms and two offices, and a small outside area with table and shade from clients use which is in the construction area and is expected to be completed by February 2024 (21 days from this report.). Medications are located in the main office in a file drawer in a locked box in the filing cabinet. LPA observed three working fire extinguishers throughout the facility, all passage ways and exits were free from obstructions and working carbon monoxide detector in the dining room area and smoke detectors in every room. LPA noted that the facility temperature was an ambient 71*f as it was 41*f outside when LPA conducted the inspection. LPA noted that facility has a food supply on site in the kitchen and prepares lunch for the clients in program. LPA observed that all bathrooms are stocked with liquid soap and paper towels. LPA note that the facility staff has met all clearance requirements. LPA noted that no violations or citations noted during the annual physical inspection of the facility.

S1 and LPA conducted a full review of the annual control tools modules. LPA noted that there were no technical, violations or citations noted of the full annual inspection review. There were no technical, violations, or citations issued on this full annual inspection.

Exit interview, report signed, and report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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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