405802253-4-28-2023-29-AS-DCHZ-CRBV4D-20230428160611

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802253
Report Date: 04/28/2023
Date Signed: 04/28/2023 04:07:18 PM

Document Has Been Signed on 04/28/2023 04:07 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:	BOB & CORKY'S CARE HOME IV		FACILITY NUMBER:	405802253
ADMINISTRATOR:	COLE, DEBRA		FACILITY TYPE:	740
ADDRESS:	2525 AUGUSTA STREET		TELEPHONE:	(805) 781-0298
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	6	CENSUS: 6	DATE:	04/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:33 AM
MET WITH:	Joel Wobrock, Licensee/Administrator, and Deborah Cole, Administrator		TIME COMPLETED:	04:30 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	Licensing Program Analyst (LPA) Chavez made an unannounced 1-year required annual visit to the facility above. LPA met with Joel Wobrock, Licensee/Administrator, and Deborah Cole, Administrator, and explained the purpose of the visit. LPA requested a staff roster, a resident roster, emergency and disaster plan, and documentation of quarterly emergency drills. LPA toured the facility with administrator and the following was noted: LPA observed the license posted, licensing reports, personal rights, non-discrimination notice, LTCO poster, CDSS Complaint Poster, Bill of Rights and Right to Residential Council. The facility has 5 bedrooms and 3 bathrooms, a kitchen, dining room/living room, courtyard in the front of the facility, and garage. Medications are kept in a locked cabinet in the garage. Physical plant was check for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, and all were in good condition. The facility maintains a comfortable temperature. The facility provides a working telephone for resident use. Smoke detectors are hard wired and were tested and operational. The carbon monoxide detector was tested and functioning properly. Fire extinguishers located in the garage and dining room were last inspected 04/07/23 and are charged in the green. There are no issues with Fire Clearance. Living and dining room furniture were also checked for functionality and condition. The living room is clean, safe and sanitary along with the dining room. Courtyard of the facility has outdoor furniture, with a covered shaded area for residents in the front yard. There are no bodies of water on the premises. There is plenty of outdoor lighting available for the safety of the residents. External gates (2) have latches and working properly. Continued on 809-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BOB & CORKY'S CARE HOME IV	FACILITY NUMBER: 405802253
	VISIT DATE: 04/28/2023

NARRATIVE

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Kitchen was sufficiently stocked with two-day perishable and seven-day non-perishables. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. The refrigerator recorded at 38F degrees and the freezer at 0 F degrees.
Resident rooms have beds with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and enough lighting for each resident. There is enough linen available to change weekly or more, if need.
Bathrooms were checked for cleanliness and proper operation. The hot water temperature measured at 112 F in resident bathrooms. Towels and washcloths are not shared. Residents have a sufficient amount of supplies for personal hygiene. Soap, paper towels and toilet paper are provided by the Licensee. Grab bars are secured in toilet and shower areas. Showers have non-slip bottoms or mats.
Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for current Medical Assessments with TB results, Current Appraisal Needs and Service plans, and signed Admission Agreements. There were no issues with documentation. Planned activities are offered to residents in care. Interviews with residents show that they are “very happy with the interesting activities available.”
Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations, Health screening with TB results, current First Aid/CPR, and Administrator Certificate. Records are in compliance. LPA reviewed Staff Training Records. Training records were present with a minimum of 20 hours completed for the past year.
Medications are in a centrally stored and locked cabinet in the garage, including over-the-counter medicines. Medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the residents’ doctor. Proper medication dispensing instructions are followed. The first aid kit has all proper items and is current.

No deficiencies cited. Exit interview conducted and the report given..

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC809 (FAS) - (06/04)

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