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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850223
Report Date: 02/16/2023
Date Signed: 02/16/2023 04:00:27 PM


Document Has Been Signed on 02/16/2023 04:00 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:BOB & CORKY'S CARE HOME VIFACILITY NUMBER:
405850223
ADMINISTRATOR:WOBROCK, JOELFACILITY TYPE:
740
ADDRESS:3198 ROSE AVE.TELEPHONE:
(805) 400-0506
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:6CENSUS: 5DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Joel Wobrock, Licensee/AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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On 2/16/23 at 2:20 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Joel Wobrock, Licensee/Administrator.

LPA toured the facility with the licensee and observed the following: LPA was not screened immediately upon entry, however, LPA was screened during the visit. Staff are wearing masks. Resident bathrooms (4) are stocked with soap and paper towels. Water temperatures were taken and fall within the regulatory range of 105F to 120F degrees. The facility has signage for COVID infection control measures including cough etiquette and handwashing reminders. Fire extinguishers are located in the kitchen next to the refrigerator and in the garage. At 2:30 pm, the extinguishers were inspected and showing fully charged, however, they were purchased on 1/24/22 and are not incompliance as they are over a year old. Deficiency cited.

At 3:00 pm, LPA conducted the Infection Control mitigation module with licensee.

Exit interview conducted, deficiency cited and the report and appeal rights given to the licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
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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Document Has Been Signed on 02/16/2023 04:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: BOB & CORKY'S CARE HOME VI
FACILITY NUMBER: 405850223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as both fire extinguishers were last purchased over a year ago which poses a potential safety risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
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Licensee will have both fire extinguishers serviced or obtain newly purchased extinguishers and provide proof of service or purchase to CCL by 2/17/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
LIC809 (FAS) - (06/04)
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