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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850222
Report Date: 12/12/2023
Date Signed: 12/12/2023 02:51:35 PM


Document Has Been Signed on 12/12/2023 02:51 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:LIFETOUCH THE ELEGANT LIVING RESIDENTIAL HOME CAREFACILITY NUMBER:
405850222
ADMINISTRATOR:AQUINO, AMELITA I.FACILITY TYPE:
740
ADDRESS:1934 TULIPWOOD DRIVETELEPHONE:
(805) 878-3409
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 4DATE:
12/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Administrator - Amelita I. AquinoTIME COMPLETED:
02:50 PM
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 10:15am on 12/12/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual facility inspection. LPA met with Administrator, Amelita I. Aquino announced who he was and the reason for the visit.
LPA conducted a tour of the facility which consist of 4 resident bedrooms, 1 staff bedroom, 3 bathrooms, living room, kitchen, dining room and outdoor area in back with shade for residents and visitors. LPA noted that there are smoke detector/carbon monoxide combos in each resident room. LPA observed the fire extinguisher primed in the green and currently tagged for service. LPA required Administrator to add two additional smoke detectors in the living room and the kitchen/dining room area for full coverage of the facility. LPA noted that all hallways and exits are free and clear of obstructions and no other fire clearance issues were noted during the facility physical tour. LPA noted that a review of the Centrally Stored Medication Records (CSMR) was conducted. Medications are stored in a locked cabinet located in the dining room area. LPA noted that the water temperature in the facility was measured within regulation range of 105*-120*(f). LPA noted that he observed at least two days of perishable and at least seven days on non perishable foods on hand. LPA noted that chemicals were locked in the closet above the washer and dryer also in the dinning room area. LPA noted that the facility appeared to be clean and in good repair. LPA noted that bedrooms had appropriate linin and storage. Each room had a working lamp, however the lamp was not connected to the wall switch in any of the resident rooms. LPA requested Administrator to provide safe lighting for each residents room.
Administrator and LPA conducted a full review of the annual care tools module. During the care tool modules a technical violation was issued for insurance not showing $3 million in aggregate, Administrator will provided proof of $3M aggregate coverage by 12/27/2023. A technical advisory was issued on lamp for resident room #3 lamp, Administrator will fix and sent proof to LPA. No other citations or violations were issued as a result of the full annual inspection.

Exit interview, report read, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
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 3