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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801992
Report Date: 11/18/2022
Date Signed: 11/18/2022 02:57:24 PM

Document Has Been Signed on 11/18/2022 02:57 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:CASA DE LUNAFACILITY NUMBER:
405801992
ADMINISTRATOR:FRANCYN ALTAMIRAFACILITY TYPE:
735
ADDRESS:8805 CARMELITA AVENUETELEPHONE:
(805) 460-7090
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 4CENSUS: 3DATE:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:Steve Rodriguez, LicenseeTIME COMPLETED:
03:15 PM
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
On 11/18/22 at 1:51 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Steve Rodriguez, Licensee, and explained the purpose of the visit.

LPA toured the facility with licensee and observed the following: The facility has infection control signage at the front door and throughout the facility on handwashing, cough etiquette and use of masks. Staff are wearing masks. The facility has soap and paper towels in resident bathrooms (2). Fire extinguishers (2) are located in the laundry room and in the storage area near the front door. The extinguishers are fully charged and were inspected on 4/27/22. The facility has a covered spa.

At 2:20 pm, LPA conducted the Infection Control mitigation module with the licensee. No deficiencies cited.

Exit interview conducted and the report emailed to the licensee and administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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