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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802289
Report Date: 11/17/2022
Date Signed: 11/17/2022 10:26:41 AM


Document Has Been Signed on 11/17/2022 10:26 AM - 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:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Malin Sickelton/Licensee TIME COMPLETED:
10:05 AM
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 At 8:00am on 11/17/2022. Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility to conduct and unannounced annual, infection control inspection. LPA met with Licensee, Malin Sickelton and announced the reason for the visit..
LPA conducted a cursory tour of the facility facility with Licensee. The facility is maintained in conformance with state fire marshal regulations. Smoke detectors and carbon monoxide detectors functioning throughout the facility. Fire extinguisher is fully charged. Inside and outside passageways are free from obstruction. There is pool and hot tub on the side of the facility that is secured by a cover with keyed locks. The facility temperature was 74 degrees F. Hot water temperature tested within regulation parameters. Residents’ rooms are appropriately furnished with adequate lighting. LPA observed more than two days of perishable and more than seven days of non-perishable food. A written disaster and mass casualty plan is readily available located on the facility Living room wall and all posting required are posted. LPA observed at least a 30 day supply of PPE in the hallway closet at the front entrance. There is a proper screening area at the front door to screen for symptom checks. LPA noted that there were no observed regulation violations during the cursory facility tour.

Licensee and LPA conducted the annual infection control module tool of the annual inspection. LPA noted that there were no violations during the annual infection control module.

Exit interview, report signed, and report emailed.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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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