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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802301
Report Date: 06/23/2020
Date Signed: 06/23/2020 04:10:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117
FACILITY NAME:A HEAVENLY HOME COMMUNITIES CFACILITY NUMBER:
405802301
ADMINISTRATOR:JIMENEZ, JENNIFER RFACILITY TYPE:
740
ADDRESS:2029 UNION ROADTELEPHONE:
(310) 889-8586
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 5DATE:
06/23/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Jennifer Jimenez/LicenseeTIME COMPLETED:
03:09 PM
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This form is amended to correct.
At 2:29pm on 06/23/2020, Licensing Program Analyst (LPA) Mark Jeffries conducted a case management visit at the facility. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit is being conducted through a tele-visit. The facility evacuated on 6/22/20 due to the River Fire and repopulated the facility on 06/23/2020. LPA toured the facility virtually and observed adequate supplies including emergency supplies, medication carts in tact and ample food supplies. LPA discussed the emergency plan with the licensee. The facility was not impacted by the fire and has no damage. There are some cellular however, all other utilities are functioning. All residents have returned to their rooms and doing well.

Exit interview, report given.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020
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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