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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801911
Report Date: 02/17/2022
Date Signed: 02/17/2022 03:32:28 PM


Document Has Been Signed on 02/17/2022 03:32 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:INGLESIDE BY THE LAKEFACILITY NUMBER:
405801911
ADMINISTRATOR:SHIRLEY BARRATTFACILITY TYPE:
740
ADDRESS:9375 MOUNTAIN VIEW DRIVETELEPHONE:
(805) 460-6494
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 5DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Shirley Barratt, Licensee/AdministratorTIME COMPLETED:
02:32 PM
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At 1:15 pm, on 2/17/2022, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced annual infection control inspection of the facility above. LPA met with Shirly Barrett, Licensee/Administrator, and explained the reason for the visit. LPA and licensee toured the facility.

LPA’s initial tour of the facility resulted in the following observations: LPA was screened upon entry to the facility by staff. The facility did not have a visitor policy posted at the front door. LPA will send the signage to licensee. Licensee will post on the front door and send a photo to LPA. LPA observed the fire extinguisher in the entrance and hallway near residence rooms. Both extinguishers are within code. LPA did not observe Provider Information Notices (PINs) nor PIN summaries posted in the facility. Licensee will print PINs and/or PIN Summaries and place in a common area.

At 1:34 pm, LPA Chavez conducted the Infection Control mitigation module with the licensee. No deficiencies noted.

Exit interview conducted and the report emailed to the licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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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