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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850017
Report Date: 06/21/2021
Date Signed: 06/21/2021 11:11:04 AM

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:COUNTRY CARE HOMEFACILITY NUMBER:
405850017
ADMINISTRATOR:BUNTE, ERIC PETERFACILITY TYPE:
740
ADDRESS:6025 BURGANDY LNTELEPHONE:
(805) 821-1049
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 5DATE:
06/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Eric Bunte/LicenseeTIME COMPLETED:
11:30 AM
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 8:40am Licensing Program Analyst (LPA) Mark Jeffries conducted a Annual Infection Control pre screening call with Licensee Eric Bunte. Licensee confirmed no residents or staff has COVID-19 positive exposure or symptoms.
LPA arrived at the facility at 8:45am, met with Licensee and announced the reason for the visit. LPA was screened for COVID-19 symptoms at time of entrance to the facility. LPA and Licensee competed the Infection control module of the annual inspection tool at 10:30am. LPA and Licensee conducted a visual inspection of the entire facility. That facility was a comfortable temperature at 75* degrees. Water temperature was tested in Kitchen and communal bathroom and tested within regulation parameters at 105.2* degrees. LPA observed two days of perishable and seven days of non-perishable foods. LPA observed smoke detectors and carbon monoxide detectors working properly. LPA observed Three resident rooms, one room single occupancy, and one privet bathroom and two rooms double occupancy with a communal bathroom. The facility is a rural property consisting of 3 bedrooms and two bathrooms on the east side of the house, a living room, a dining room and kitchen in the center and live in staff have a family room, bedroom and bathroom on the west side of the facility. There is an outside patio that has shaded areas for residents. All exit doors have auditor monitors for delayed regress. LPA did not observe any violation of regulations or hazards to residents during the walking tour of the facility. ,

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

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
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