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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850017
Report Date: 08/12/2024
Date Signed: 08/12/2024 11:19:47 AM


Document Has Been Signed on 08/12/2024 11:19 AM - 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: 3DATE:
08/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licnesee, Eric BunteTIME COMPLETED:
11:38 AM
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 At 9:30am on 08/12/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to conduct an annual facility inspection. LPA met with Licensee/Administrator Eric Bunte announced who he was and the reason for the visit.
Licensee and LPA conducted a physical tour of the facility. LPA noted that this is a 3 bedroom, all rooms are double resident occupancy and two bathrooms, bathroom one is in a master bedroom and the other bathroom is in the hallway. Both bathrooms have secure handicap handrails, nonskid mats, properly functioning appliances, stocked, liquid soap and paper towels are also present in both bathrooms. All bedrooms have enough storage space according to regulations, lights are working and beds have linins that me regulation requirements. LPA noted that each bedroom has a wired smoke detector and smoke detectors in common areas of home, which are all hardwired. There is working carbon monoxide detector in the hallway and bedroom number 1.. LPA observed two fire extinguishers in the green and purchased within the last 6 months with sales receipt attached. LPA noted that all exits are free and clear of obstructions. LPA observed the outside of the facility, with a substantial pergola for resident to recreated outside in the shade. LPA observed at least 2 days of perishable and seven days of non-perishable foods on hand. LPA noted that resident files, staff files and medications are locked in a cabinet in the dining room area. LPA conducted a sample medication inspection and review of Centrally Stored Medication Records (SCMR) found no regulation violations. LPA reviewed staff and resident files, LPA also reviewed staff training records and found no regulation violations.
Licensee and LPA conducted the review of each module of the care tools inspection tool. LPA noted that there were no violations of during the review of all of the care tool modules. At this time LPA found no violations of care tool module and physical inspection of the facility at this time.
Three Residents and 2 staff interviewed.

Exit interview, report read, report singed, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
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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