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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802277
Report Date: 05/14/2022
Date Signed: 05/14/2022 01:40:27 PM


Document Has Been Signed on 05/14/2022 01:40 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 VFACILITY NUMBER:
405802277
ADMINISTRATOR:CORRALES, NELLIEFACILITY TYPE:
740
ADDRESS:3210 FLORA STREETTELEPHONE:
(805) 439-2504
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:6CENSUS: 6DATE:
05/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Joel Wobrock, Licensee/AdministratorTIME COMPLETED:
02:00 PM
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On 5/14/22 at 1:14 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Joel Wobrock, Licensee/Administrator, and explained the purpose of the visit.

LPA toured the facility with the licensee and observed the following: The facility has infection control signage at the front door and signage throughout the facility on cough etiquette, handwashing and use of masks. Upon entry to the facility, LPA was screened. Staff are wearing masks. The facility has soap and paper towels in resident bathrooms (4). The fire extinguishers (2) are located in the hallway near the kitchen and in the garage. The extinguishers are fully charged and were inspected on 4/11/22. Licensee stated that residents’ dentist information is not currently on the emergency info sheet. Licensee has committed to adding this information and sending a photo or copy to LPA by 5/17/22.

At 1:26 pm, LPA conducted the Infection Control mitigation module with the licensee. No deficiencies cited.

Exit interview conducted and report emailed to the licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2022
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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