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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801985
Report Date: 06/07/2021
Date Signed: 06/07/2021 03:52:38 PM

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:PASO SENIOR CAREFACILITY NUMBER:
405801985
ADMINISTRATOR:MEYNARD MARCOSFACILITY TYPE:
740
ADDRESS:197 CARDINAL WAYTELEPHONE:
(805) 835-4762
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 5DATE:
06/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Meynard Marcos/LicenseeTIME COMPLETED:
03:00 PM
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At 9:30am on 06/07/2021, Licensing Program Analyst (LPA) Mark Jeffries made telephone contact with Licensee Meynard Marcos to screen facility for the annual infection control module inspection. Licensee stated that no COVID-19 related cases or screening question indicated COVID-19 positive facility.
At 10:12am, time of entrance to the facility, LPA was asked to screen and sign in under normal COVID-19 protocol question. At 10:24am License and LPA conducted a walking tour and cursory inspection of the facility. The facility is has six bedrooms, 3 and a half bathrooms. Current census of 5 allows all residents to have single occupancy rooms. During the walking inspection, LPA tested the water at all interior faucets of the facility, between 109.7 - 111.2 degrees Fahrenheit. LPA observed all necessary posted documentation posted on the facility wall just to the right of the entrance as well as on and above the screening station. LPA observed 2 days perishable and 7 day non-perishable foods. LPA observed sharps locked in single drawer in the kitchen. LPA observed a new fire extinguisher with receipt posted in the living room. Licensee and LPA tested fire alarm and carbon monoxide alarms to be functioning properly. The facility interior temperature was 68 degrees Fahrenheit. LPA observed medication cabinet and Medication Administration Records (MAR) LPA provided suggestions to Licensee for organization of medication but did not find any regulation deficiencies. LPA observed a sufficient supply of Personal Protective Equipment (PPE) in the kitchen and Garage and Licensee has more PPE supply at other licensed locations. At 11:18am Licensee and LPA conducted Infection Control module portion of the annual inspection. Licensee and LPA discussed origination of medication cabinet and MARs tracking. At this time LPA found the facility to be in compliance with Title 22 regulations.

Exit interview, report signed, report emailed
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
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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