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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802255
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:28:37 PM

Document Has Been Signed on 09/15/2022 02:28 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:GALLAGHER ADULT FAMILY HOMEFACILITY NUMBER:
405802255
ADMINISTRATOR:HICKS, AMYFACILITY TYPE:
735
ADDRESS:809 VISTA CERRO DRIVETELEPHONE:
(805) 391-3287
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 4CENSUS: 3DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:08 AM
MET WITH:Licensee/Jennifer GallagerTIME COMPLETED:
10:15 AM
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 At 8:00am on 09/15/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility to conduct and unannounced infection control annual inspection. LPA was properly screened at the door by Licensees son Gannon Gallager. LPA announced who he was and the reason for the visit.

At 8:10am LPA and Licensee reviewed the facility. This is a 4 bedroom, 4 bathroom home. There are two clients sharing a one of the rooms and the other client is in a single room. LPA noted that the faculty is clean and in good repair. There is a new addition of stairs and an open space added to the home, LPA advised Licensee to submit new facility sketch, fire clearance, and city permit for the addition to CCLD and LPA through email (CCLASCPWoodlandHillRO@dss.ca.gov). LPA noted that the facility has two days of perishable an seven days of non-perishable foods on hand. LPA noted that all fire alarms and carbon monoxide detectors are fully functioning. LPA noted that all persons that are living in the facility are cleared in FAS and guarding checks. LPA noted that all bathrooms have paper towels and liquid soap stocked.

At 9:00am Licensee and LPA conducted infection control module of the annual inspection. LPA noted that no deficiencies were discovered and not citation issued.

Exit interview, reprot signed, and report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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