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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802289
Report Date: 12/12/2024
Date Signed: 12/12/2024 03:58:51 PM

Document Has Been Signed on 12/12/2024 03:58 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/
DIRECTOR:		SICKELTON, MALINFACILITY TYPE:
735
ADDRESS:1314 CROWN WAYTELEPHONE:
(805) 239-4205
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 3CENSUS: 10DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH: Administrator, Garrett HanneTIME VISIT/
INSPECTION COMPLETED:
04:08 PM
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 At 1:58pm on 12/12/2024. Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility to conduct and unannounced annual inspection. LPA met with Licensee Malin Sickelton and announced the reason for the visit.

LPA toured 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 which has regulation height fence and hot tub on the side of the facility that is secured by a cover with keyed locks. The facility temperature was comfortable 72 degrees (f). Hot water temperature tested and is within regulation parameters of 105* -120* (f). 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 by the front door. LPA reviewed staff and client files, emergency disaster plan, and infection control plan. LPA noted that the facility is a Tri Counties Regional Center (TCRC) Level 2 and all clients exercise a high level of independence. LPA reviewed centrally stored medication records. Medications are stored in a locked cabinet in the laundry room. There is a signed and dated order from a physician for prescription and PRN medication. LPA observed the medication administration record (MAR) and medications are given per physician's orders. LPA noted no violations or citations during physical tour of the facility’.

Licensee and LPA conducted a full review of the annual care tools module. LPA noted that no technical, deficiencies, violations, or citations were noted during the full annual inspection and full care tools review. LPA interviewed 1 staff and 1 client.

Exit interview, no deficiencies cited, and report provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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