421701694-4-27-2023-29-AS-JOLN-CRARPX-20230427131240

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 421701694
Report Date: 04/27/2023
Date Signed: 04/27/2023 01:14:08 PM

Document Has Been Signed on 04/27/2023 01:14 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:	GANTOUS HOME		FACILITY NUMBER:	421701694
ADMINISTRATOR:	GANTOUS,SHELBY&CAROL		FACILITY TYPE:	735
ADDRESS:	1514 NORTH MILLER ST		TELEPHONE:	(805) 925-6734
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY: 1		CENSUS: 1	DATE:	04/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Carol Gantous, Administrator/Licensee		TIME COMPLETED:	01:30 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

Licensing Program Analyst (LPA) Jenny Olson arrived unannounced to conduct a one year required annual visit. The LPA met with Licensee/Administrator Carol Gantous and explained the reason for the visit.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The facility has a sufficient supply of non-perishable and perishable food items. Cleaning supplies and disinfectants are stored under the sink. Knives are stored in a cabinet in the kitchen.

Common areas: Living and dining room furniture were observed to be in good condition. At 12:00 p.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was charged and serviced recently. The hot water temperature measured at 118.9 degrees Fahrenheit.

The backyard has an area equipped with furniture for client use. No bodies of water noted. The washer and dryer are in the garage. The garage is not locked.

Restrooms: The client restroom was clean and sanitary and in operating condition with non-skid surface mat. The bathroom was sufficiently stocked with soap and paper towels.

Bedrooms: There is one (1) client bedroom, which was furnished with appropriate linens and required furniture. A linen closet was located outside of the room which was stocked extra linens and towels.

Records: The LPA reviewed client and staff records at 11:00 a.m. LPA reviewed one (1) client file for, but not limited to, the following: signed admission agreements, medical assessments with TB results, and current needs and services plan. All files were complete.

Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

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 6

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: GANTOUS HOME	FACILITY NUMBER: 421701694
	VISIT DATE: 04/27/2023

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
26
27
28
29
30
31
32

LPA reviewed two (2) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. One staff was missing a personnel record.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 2 home. The last disaster drill was conducted on 1/9/2023.

Medications: Medications are not centrally stored. Client is taking one medication which was labeled and checked for expiration date.

Infection Control: The facility does not have an infection control plan. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Exit interview conducted, a copy of the report was issued.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6