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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801955
Report Date: 07/20/2022
Date Signed: 07/21/2022 07:29:12 AM


Document Has Been Signed on 07/21/2022 07:29 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:ANNETTE LODGEFACILITY NUMBER:
405801955
ADMINISTRATOR:KATHLEEN M. TUCKERFACILITY TYPE:
740
ADDRESS:725 PINE STREETTELEPHONE:
(805) 226-9500
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:19CENSUS: 14DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Garrett Haner/AdfministratorTIME COMPLETED:
11:45 AM
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At 9:00am on 07/20/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility to conduct the annual infection control inspection. LPA was screened at the front entrance for COIVD-19 protocols upon entering the facility with AccuShield automated screening. LPA met with Marcos Ibarra (S1), introduced himself and announced the reason for the visit.

At 9:05am, S1 and LPA conducted a walking tour of the entire facility. The facility has 14 single resident bedrooms all with bathrooms within all 14 of the rooms. All the rooms are single occupancy with the exception of a married couple currently occupying a single room at this time. The facility has a kitchen, dining area and 4 common areas on each wing of the facility. The facility has a large courtyard with ample shade and seating to accommodated residents and their visitors and foster social distancing during activities, leisure time and visits. Fire alarms are hard wired throughout the facility and serviced by Great Western Alarm annually. During the walking tour LPA did not observe any hazards that would put residents in any danger. LPA made observations of properly supplied rooms and bathrooms of infection control measure such as hand sanitizer, paper towels and cleaning supplies in resident rooms. Single entry point with comprehensive COVID screening station supported by the Accushield screening device and single entry point at front entrance. .

At 9:40am facility administrator, S1 and LPA conducted the infection control module of the annual infection control inspection. There were no line items in the infection control module that were not met at this inspection. There were no violations or citations present during this annual infection control module inspection at this time.

Exit interview conducted, report singed and report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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