405801856-6-1-2023-29-AS-MJES-CSDSTN-20230601140946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801856
Report Date: 06/01/2023
Date Signed: 06/01/2023 02:10:10 PM

Document Has Been Signed on 06/01/2023 02:10 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:	A HEAVENLY HOME, LLC		FACILITY NUMBER:	405801856
ADMINISTRATOR:	JENNIFER R. JIMENEZ		FACILITY TYPE:	740
ADDRESS:	1920 PROSPECT AVENUE		TELEPHONE:	(805) 296-3239
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	6	CENSUS: 4	DATE:	06/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Jennifer Jimenez / Administrator		TIME COMPLETED:	02:07 PM

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

At 9:15am on 06/01/2023, Licensing Program Analyst (LPA) Mark Jeffries arrived unannounced to the facility to conduct the annual inspection. LPA met with Administrator Jennifer Jimenez, Marco Jimenez, additional Administrators Karla Sanchez and Clementina Garcia. LPA announced who he was and the reason for the visit.

Administrator, staff and LPA conducted a physical tour of the facility. This facility is 4 bedroom and 2 shared bathroom facility. There is a locked room which contains a medication cart that is locked, a small refrigerator that has a pad lock and the facilities first aide kit. LPA observed resident bedroom to all have appropriate linin, lighting and storage. LPA observed there to be at least 2 days of perishable foods and at least 7 days of non perishable foods on hand. LPA noted that all meals are stored cooked and prepared at adjacent facility on the campus property. LPA observed all required postings and emergency disaster plan. LPA observed that smoke detectors are also all carbon monoxide detectors as well and are all hardwired throughout the facility. LPA observed a working fire extinguisher currently tagged and in the green pressure range. LPA noted that the facility is clean and in good repair, all exits are clear and free of all hazards. LPA conducted a medication audit and found that Centrally Stored Medication Record (CSMR) to be missing entries. Facility Administrator assigned a staff to correct the entries during this inspection. Administrator will email a completed CSMR by 5pm on 06/02/2023. LPA did not find any other violations, technical or citations during the physical tour walk through.

Administrator, staff and LPA conducted the read through of all the care tool modules. LPA noted that a technical violation was issued and corrected during the inspection for the CSMR. LPA noted that there were no other citations, violations, or technical issued during the control module. LPA conducted 4 of 4 staff interviews, however that staff interview tab was not functioning at time of inspection.

Exit interview, Technical violation issued and corrected, report read, and report provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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