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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802304
Report Date: 02/11/2023
Date Signed: 02/11/2023 04:17:32 PM


Document Has Been Signed on 02/11/2023 04:17 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 COMMUNITIES AFACILITY NUMBER:
405802304
ADMINISTRATOR:JIMENEZ, JENNIFERFACILITY TYPE:
740
ADDRESS:2025 UNION ROADTELEPHONE:
(805) 296-3239
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 6DATE:
02/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Marco and Jennifer Jimenez/LicenseeTIME COMPLETED:
02:01 PM
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 At 11:45am am on 02/11/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual, infection control inspection. LPA met with Med-Tech Lauren Romines (S1). LPA announced who he was and the reason for the visit. S1 contacted Jennifer and Marco Jimenez who arrived at the facility shortly after S1 contacted.

Licensees and LPA conducted a cursory tour of the facility. This is a six bedroom, seven bath facility, with kitchen, dining room, living room and food storage area. This facility serves as the main kitchen and food storage area for the other 5 homes on this facilities campus. LPA observed more than 2 day supply of perishable and more than seven days supply on non-perishable foods. LPA noted that the water temperature in the facility is within regulation parameters of 105* - 120* (f). LPA noted that the facility resident rooms are single occupancy with privet on suite bathrooms in each room. LPA noted that fire detectors and carbon monoxide detectors are operational and functioning properly. Medication is a locked and secured mobile cart located at the front of the facility. LPA observed more than 30 days supply of PPE on hand. LPA noted that each bathroom in the facility has liquid soap and paper towels. LPA noted that there is infection control screening station at the front door of the facility and there is are universal screening precautions upon entrance to the campus the facility is located. LPA noted that the faculty is exceptionally clean and in good repair. All exits are free and clear of hazards and there is plenty of space inside and out side of the facility for residents. LPA noted that there were no violations, technical, or citations issued during the cursory walk through tour.

Licensees and LPA conducted the annual, infection control module of the annual inspection. LPA noted that there were no violation, technical or citations issued during the infection control module. LPA noted that there are no violations, technical or citations issued on this annual inspection at this time.

Exit interview, report read, report signed and report issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2023
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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