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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801974
Report Date: 12/22/2022
Date Signed: 12/23/2022 07:57:50 AM

Document Has Been Signed on 12/23/2022 07:57 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:MIRIAM'S PLACEFACILITY NUMBER:
405801974
ADMINISTRATOR:MIRIAM Y. SALAMANCAFACILITY TYPE:
740
ADDRESS:1728 ROYAL COURTTELEPHONE:
(805) 541-4054
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY: 6CENSUS: 5DATE:
12/22/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Herbert Salmanca / Administrator TIME COMPLETED:
03:00 PM
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 At 1:05pm on 12/22/2022, Licensing Program Analyst (LPA) De Leon and Jeffries arrived unannounced at the facility to conduct and Plan of Correction visit. LPA's viewed a roster for Medication Training schedule on 12/16/2022 for 5 facility staff members for the Medication Training. Additionally LPA's observed Mr. Salamanca call Hospice, Family members and Physicians office to request current medications list. LPA's discussed with Mr. Salamanca that the Medication Administration Records (MAR's) for January 2023 will be submitted for review to LPA on January 2nd 2023. LPA Jeffries will follow up on January 2, 2023 to review doctors medication orders and MAR's.
All of the 4 plans of correction have been met but the facility and will be cleared on 12/22/2022.

Exit interview, report singed and report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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