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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850130
Report Date: 02/16/2023
Date Signed: 02/16/2023 02:45:09 PM

Document Has Been Signed on 02/16/2023 02:45 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:GINA SCHWICHTENBERG ARF IIFACILITY NUMBER:
405850130
ADMINISTRATOR:SCHWICHTENBERG, GINAFACILITY TYPE:
735
ADDRESS:285 HEADWATERS RDTELEPHONE:
(805) 286-4008
CITY:TEMPLETONSTATE: CAZIP CODE:
93465
CAPACITY: 4CENSUS: 4DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Trey Correy / Primary StaffTIME COMPLETED:
12:31 PM
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 At 10:00am on 02/16/2023, Licensing Program Analyst (LPA) Jeffries, arrived unannounced at the facility to conduct the annual, infection control inspection. LPA met with Primary Staff Trey Correy (S1) announced who he was and the reason for the visit.
S1 and LPA conducted a cursory tour of the facility. The facility is a three bedroom two bathroom, living room, kitchen and dinning area. The laundry room is locked and that is where the chemicals, medication and staff and client files are kept, all in separate cabinets. There is a patio with shade pergola in the back yard for client to use. There are two client bedrooms that are dual occupancy and one master bedroom for the live-in staff. The clients share a full bathroom and the other bathroom is the on-suite bathroom in the master bedroom designated as staff bedroom and bathroom. LPA observed liquid soap and paper towels in the bathroom. LPA tested and noted the facility water temperature to be within regulation range of 105*-120* (f). LPA observed a first aide kit and fire extinguisher, also in the laundry room. LPA noted that fire extinguisher are located in each room throughout the facility and the carbon monoxide detectors in the hallway all tested and functioning as normal. LPA observed at least two days of perishable foods and more than seven days of non-perishable foods on hand at this facility. LPA observed a 30 day supply of PPE on hand at the facility. LPA advised S1 that all staff are to be fit tested and the appropriate sized N-95 mask should be available for the different fit tested sizes if necessary. LPA and S1 reviews cleared persons on the facility roster to be accurate for staff scheduled at this facility. LPA noted that the facility was new, clean and in good repair. LPA noted that all doors and exits were free of obstructions. LPA noted that no violations, technical, or citations were issued as a result of the cursory walk through inspection tour.
S1 and LPA conducted the infection control module of the annual inspection. Additionally, LPA discussed with S1 current best practice foundations outlined in Provider information Notice (PIN) 23-02. LPA noted that there were no violations, technical, or citations issued as a result of the infection control module of the annual inspection. LPA noted that no violations, technical, or citations were issued at this time of the annual inspection visit.
Exit interview, report signed, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
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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