<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801962
Report Date: 11/02/2022
Date Signed: 11/02/2022 11:25:44 AM


Document Has Been Signed on 11/02/2022 11:25 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:SINGLETREE CARING HANDSFACILITY NUMBER:
405801962
ADMINISTRATOR:HERBERT SALAMANCAFACILITY TYPE:
740
ADDRESS:1789 SINGLETREE COURTTELEPHONE:
(805) 439-1119
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:6CENSUS: DATE:
11/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:TIME COMPLETED:
10:55 AM
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 9:45am on 11/02/2022, Licensing Program Analyst (LPA) Jeffries, arrived at the facility to conduct and unannounced visit to determine if all residents have been transferred to other facilities and the facility is no longer providing care for persons at this location. LPA knocked on the door with no answer at 9:45am. LPA attempted to contact Herbert Salamaca, Licensee by phone with no answer. LPA left a message and a text to call back. at 9:50am. Arsenio Anges, arrived at the facility at 10:00am. Mrs. Anges contacted Licensee and gave permission over the phone for LPA to tour facility.
LPA observed that bedrooms 1, 2,3 and 4 had no beds and bedroom 5 had a deconstructed bed. LPA observed moving boxes in the hallway. LPA observed Intal staging of furniture being prepped to move. LPA noted that Licensee stated over the phone that they were going to U-hall today and going to move as much furniture as they could today. LPA did not observe any evidence that this facility is currently providing care for residence, as no residents were present. LPA will conduct transfer checks on last 4 residents in care in the next 10 days.
Exit interview, 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: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
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 1