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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850403
Report Date: 03/08/2024
Date Signed: 03/08/2024 01:59:01 PM


Document Has Been Signed on 03/08/2024 01:59 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:ANNETTE LODGEFACILITY NUMBER:
405850403
ADMINISTRATOR:HANER, GARRETTFACILITY TYPE:
740
ADDRESS:725 PINE STREETTELEPHONE:
(805) 266-9500
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:19CENSUS: 14DATE:
03/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH: administrator Garrett Haner-TomaskoTIME COMPLETED:
01:45 PM
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At 11:30am Licensing Program Analyst (LPA) Jeffries arrived announced to the facility to conduct a pre-licensing facility inspection. LPA met with facility administrator Garrett Haner-Tomasko announced who he is and the reason for the visit.
This facility is located adjacent to downtown Paso Robles. At 11:45am Administrator and LPA conducted a walking tour of the entire facility. The facility has 14 single resident bedrooms all with bathrooms within all 14 of the rooms. The facility has a kitchen, dining area and 4 common areas separated of two wings of the facility. The facility has a large courtyard with ample shade and seating to accommodated residents and their visitors and foster social distancing during activities, leisure time and visits. Fire alarms are hard wired throughout the facility and serviced by Great Western Alarm annually, their last inspection was completed on 11/01/2023. Mid Coast Fire Protection tested the pressured sprinkler system on 02/15/2024 LPA observed at least 2 days on perishable foods and at least 7 days of perishable foods. LPA noted that the facility water temperature was tested throughout the facility and was with in regulation limits. LPA noted that all rooms and bathrooms maintained within regulations standards. LPA observed and noted that all required postings were posted in a prominent location in the facilities front entrance and right of the entrance. LPA noted that all hazardous materials were locked. LPA noted that there are two medication carts is locked and located in locked closets on different wings of the facility.
Administrator and LPA conducted a full review of the pre licensing care tools modules. LPA noted no technical, violations, or citations issued as a result of the full pre-licensing tools modules review. LPA noted that no other technical, violation, or citation were noted on the full review of the pre licensing care tools review and no violations or citations were issued a result of the facility walk through inspection.
Administrators and new licensee have recently conducted the COMP III requirements and a LIC812 has been created to forego the COMP III class, as it has previously been administered

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: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
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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