<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802301
Report Date: 10/15/2022
Date Signed: 10/15/2022 04:53:25 PM


Document Has Been Signed on 10/15/2022 04:53 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: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: 6DATE:
10/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Licensee's / Marco and Jennifer Jimenez TIME COMPLETED:
12:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
 At 8:30am on 10/15/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct an annual infection control inspection. LPA met with Licensee's Marco and Jennifer Jimenez and announced the reason for the visit.

At 10:30am Licensees conducted a cursory tour of the facility. The facility is a 6-bedroom, 7-bathroom, kitchen and living room open area, the facility is one facility of five six bed facilities that are located on the same grounds, all facilities share a large outdoor area with shade for residents to be outside. LPA observed more than 2 days of perishable and more than 7 days of non-perishable foods. LPA noted that lunch and dinner are prepared in the adjacent six bed facilities on this campus and delivered to this facility daily. This facility still maintains a regulation acceptable supply of food at this facility. LPA observed the fire detectors and carbon monoxide detectors have green lights and in working condition. LPA observed a clean and in good repair facility with not obstruction to exits and no visible hazards to residents in care. LPA noted that each of the six bedrooms are single occupancy with their own privet bathroom and there is an additional guest bathroom all stocked with liquid soap and paper towels. LAP observed more than a day supply of PPE located on the campus in the storage garage attached to facility C. LPA noted that the water temperature in the facility is within regulation parameters (95*-120*f) LPA noted that during the cursory inspection tour of the facility there were no visible regulation violations, and no deficiencies or citations were issued at this time.

LPA and Licensee's conducted the annual infection control module portion of the inspection. LPA noted that there were no deficiencies during the annual infection control module and no citations were issued at this time.

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: 10/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1