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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703604
Report Date: 07/13/2022
Date Signed: 07/13/2022 08:53:12 AM


Document Has Been Signed on 07/13/2022 08:53 AM - 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:ORCUTT BOARD AND CARE HOMEFACILITY NUMBER:
421703604
ADMINISTRATOR:ANNIE YAGUEFACILITY TYPE:
740
ADDRESS:263 CRESCENT AVE.TELEPHONE:
(805) 934-2586
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:6CENSUS: 2DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Licensee/Annie YagueTIME COMPLETED:
10:30 AM
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 2:00pm on 07/11/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct the annual infection control module inspection. LPA met with Licensee Annie Yague and announced who he was and the reason for the visit.

LPA and and Licensee took a walking tour of the facility and the facility grounds. This facility is a 8 bedroom 4 bathroom (6 resident bedrooms and 2 staff bedrooms), 2 living rooms, kitchen, dining room, indoor patio, side yard and back yard. The medications storage is located in a lockable cabinet to the left of the refrigerator. Staff and Resident files are located in a locked file cabinet between the kitchen and the dining room. LPA advised Licensee to clear the assisted walking devices from covered patio so that area has safe access. Fire and Carbon Monoxide detectors are working throughout the facility. LPA did auditable observe the delayed regress at the front door in working order. Licensee has at least a minimum 30 day supply of PPE at the facility. LPA did not observe any noticeable regulation violations during the walk through at this time.

LPA and Licensee began the annual infection control module of the infection control inspection. LPA and Administrator completed 39 of 73 question of the infection control module. Administrator was reminded of an pre schedule appointment when her ride showed up at the facility. LPA saved the completed module questions and will return at a later date to finish the inspection. (07/11/2022 at 2:00pm)

At 8:00am on 07/13/2022, LPA returned to facility to complete the annual infection control inspection. LPA met with Licensee Annie Yague. LPA and Licensee completed the remainder of the infection control module with no deficiencies observed.

Exit interview, report singed and report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022
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 1