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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802295
Report Date: 05/13/2022
Date Signed: 05/13/2022 03:02:49 PM


Document Has Been Signed on 05/13/2022 03:02 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:RESIDENCE IV, THEFACILITY NUMBER:
405802295
ADMINISTRATOR:MARCOS, MEYNARDFACILITY TYPE:
740
ADDRESS:347 CALLE LUPITATELEPHONE:
(805) 549-0328
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:6CENSUS: 4DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Meynard Marcos, Licensee/Administrator, and Desarae Verry, AdministratorTIME COMPLETED:
03:15 PM
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On 5/13/22 at 2:03 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Meynard Marcos, Licensee/Administrator, and Desarae Verry, Administrator and explained the purpose of the visit.

LPA toured the facility with the administrator and observed the following: The facility has infection control signage at the front door. The facility is missing signage in the facility on handwashing, cough etiquette and use of masks. Licensee will post signage throughout the facility, take photos, and send to LPA by 5/16/22. Upon entry to the facility, LPA was screened. Staff are wearing masks. The facility has soap and paper towels in resident bathrooms (3). The fire extinguisher is located on the kitchen island. The extinguisher is fully charged and was purchased on 6/05/21. A panel on the southwest backyard patio covering is coming up in the wind and could be a potential safety hazard, if the panel flew off. Licensee will secure the panel and send a video to LPA by 5/16/22 showing that it is secure.

At 2:32 pm, LPA conducted the Infection Control mitigation module with the administrator. 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: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022
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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