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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850017
Report Date: 07/29/2022
Date Signed: 07/29/2022 04:11:24 PM


Document Has Been Signed on 07/29/2022 04:11 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: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: 4DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Eric Bunte/LicenseeTIME COMPLETED:
09:45 AM
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 At 8:00am on 07/29/2022, Licensing Program Analyst (LPA) Jeffries arrive at the front door announced the reason for the visits, the annual infection control inspection visit. LPA was screened for COVID-19 protocols at the time of entrance. LPA met the Licensee Eric Bunte and announced the reason for the visit.
Licensee and LPA conducted a walking tour of the facility. The facility is located in a rural country area, with fire station located at the opposite end of the road. The facility is a 4 bedroom, 3 bathroom with kitchen, living room and dining room. Three bedrooms have double occupancy and share two resident bathrooms. Bathrooms are stocked with liquid soap and paper towels, all three bedroom have hand sanitizer. The fourth bedroom and third bathroom are staff live-in quarters and are located on the opposite side of the facility from the resident bedrooms and bathrooms. LPA observed the medication closet in the kitchen/dining room area and staff and resident files are in a locked cabinet. There is a large covered patio in the back yard set up for outdoor recreational activities that included a large Television and recliners for the residents with shade and fans. LPA observed more than a two day supply of non perishable foods and more than a seven day supply of perishable foods. LPA made note of an exit door to the back yard that had plants that needed to be moved for safety, and Licensee complied and relocated plants. LPA checked fire detectors and carbon monoxide detectors all in good working condition. LPA observed and ample amount of PPE supplies. LPA did not discover any visible deficiencies or citations at this time during the facility tour.

LPA and Licensee conducted the Annual Infection control model portion of the inspection. There were no deficiencies or citations discovered at this time during the annual Infection Control inspection.
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: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
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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