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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802301
Report Date: 12/15/2023
Date Signed: 12/15/2023 02:57:44 PM


Document Has Been Signed on 12/15/2023 02:57 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:
12/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator - Clemitina GarciaTIME COMPLETED:
02:00 PM
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 At 9:00am on 12/15/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conducted the annual facility inspection. LPA met with Licensee's Marco and Jennifer Jimenez, and Administrators Clemitina Garcia and Karla Sanchez announced who he was and the reason for the visit.
LPA noted that the facility is one of five, 6 bed facilities on approximately 2 acres that is gated and there is a recreation building and expansive open court yard for residents and visitors. During todays inspection, LPA conducted annual inspections on three of the five facilitates.
This facility is a 6 bedroom, 7 bathroom, single occupancy, with living room, dining room and kitchen, The medications are stored in a locked medication cart in the facility hallway. There are combo smoke detectors/carbon monoxide detectors throughout the facility that are hardwired with backup battery. Apex Fire and Safety conducted a successful annual compression test for the facilities fires sprinkler system on all 5 facilities on 12/07/2023. LPA noted that the facility is clean and in good repair with no obstructions in hallways doorways or exits. LPA observed fire extinguishers that were tagged current and in the green compression range. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records (CSMR) and found no violations or citations. LPA noted that the facilities has food and snacks in the kitchen. LPA noted that all resident meals are prepared and cooked in facility A (1) and delivered to each facility by hand. LPA noted that resident special diets or communicated to the facilities chief via electronic AP and computer printout. LPA observed at least two days of perishable foods and seven days of non perishable on hand for this facility and the additional four facilities. LPA conducted a staff and resident file review and noted to violations or deficiencies.
LPA and Licensees conducted a full review of the annual care tools modules. During the full review LPA noted that there were no violations or citations discovered. LPA noted that the full annual review and facility tour there were no violations or citations discovered or issued.

Exit interview, report read, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
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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