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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802289
Report Date: 01/27/2022
Date Signed: 01/27/2022 05:56:10 PM

Document Has Been Signed on 01/27/2022 05:56 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:SICKELTON ADULT HOMEFACILITY NUMBER:
405802289
ADMINISTRATOR:SICKELTON, MALINFACILITY TYPE:
735
ADDRESS:1314 CROWN WAYTELEPHONE:
(805) 239-4205
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 3CENSUS: 2DATE:
01/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Maylin Sickelton, Licensee/AdministratoTIME COMPLETED:
01:22 PM
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At 11:50 am, on 1/27/2022, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced annual infection control inspection of the facility above. LPA met with Maylin Sickelton, Licensee/Owner, and explained the reason for the visit. LPA and licensee toured the facility.

LPA’s initial tour of the facility resulted in observations which were immediately corrected. LPA was screened upon entry to the facility by staff. Kitchen water temperature was at 117.1 F, bathroom #1 at 110.1 F and bathroom #2 at 115.9 F. Licensee has agreed to ensure all staff are fit tested for N95 respirators and provide a certification and staff sign-in sheet. At 12:10 pm, LPA observed that the facility does not have a CCLD reporting poster. Licensee will print and post a 20”x26” color poster in the facility in a common area. At 12:15 pm, LPA observed a backyard gate leading to the driveway which is not closing properly. Licensee states the spring needs replacing and will do so immediately.

At 12:25 pm, LPA conducted the Infection Control mitigation module with the licensee. No deficiencies noted.

Exit interview conducted and report emailed to the licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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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