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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801985
Report Date: 06/20/2023
Date Signed: 06/20/2023 12:46:13 PM


Document Has Been Signed on 06/20/2023 12:46 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: 6DATE:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Meynard Marcos / AdministratorTIME COMPLETED:
12:45 PM
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 At 8:45am on 06/20/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual inspection. LPA met with Administrator Meynard Marcos, announced who he was and the reason for the visit.
Administrator and LPA conducted a physical tour of the facility. LPA noted that all exits were free and clear of hazards. LPA noted that all rooms have a working combination carbon monoxide/smoke detector unit that are all hardwired and currently working. LPA noted that all rooms are properly finished with correct bedding linin, personal storage and lighting in accordance with regulations. LPA noted that there is ample linin and personal hygiene and incontinence supplies for all 6 residents presently at the facility. This facility has 5 resident bedrooms, 4 are single occupancy and 1 in double occupancy. The facility has 3 bathrooms all meeting regulations standards. Water in the facility was tested at bathroom 1 and bathroom 3 and found to be within the regulation temperature range of 105*-120* (f). LPA observed there to be more than 2 days of perishable foods and more than 7 days of non-perishable foods for the 6 residents of the facility. LPA observe the outside grounds of the facility and noted that patio tables have table umbrellas for shade when residents are utilizing outdoor area of facility. LPA noted that one screen needed replacement and one screen needed minor repair acknowledged by Administrator to be already scheduled for repair. LPA noted that the facility to be clean and in good repair with no hazards present on facility physical tour. LPA found no technical, violations or citations during the physical tour at this time.
Administrator and LPA conducted a full review of the annual control modules tools. LPA noted that there were no technical, violations or citations issued as a result of the annual control module care tools kit. There were no technical, violations, or citations issued as a result of this full annual inspection.

Exit interview, report read, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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