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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801985
Report Date: 06/20/2022
Date Signed: 06/20/2022 04:28:03 PM


Document Has Been Signed on 06/20/2022 04:28 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: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:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:Mylene Cavello/House LeadTIME COMPLETED:
02:33 PM
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 At 12:10pm on 06/20/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility to conduct the annual infection control inspection. LPA met with lead house care giver Mylene Cabello (CG1) and announced the reason for the visit. Licensee/Administrator Maynard Marcos was in Philippines and was contacted by phone at 12:30pm, at that time allow Licensee allow for CG1 to sign for this inspection.

At 12:35pm CG1 and LPA conducted the infection control module portion of the annual inspection. At that time there were no deficiencies discovered in the infection control module portion. LPA noted that the 10 day supply of PEE was questionable. Administrator called back at 12:44pm and placed an Amazon order for additional PPE supply's to meet or exceed the 30 day requirement. No other issues were found on the infection control module. And deficiencies cited on the infection control module portion.

CG1 and LPA conducted a tour of the facility. The facility has 5 bedrooms, 3 bathrooms a living room, kitchen area, laundry room, kitchen and backyard that has shade from residents. The facility has ample food supply in accordance with regulations. During the tour LPA did not observe any noticeable deficiencies at this time and no decencies were cited. .

Exit interview, report signed and copy provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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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