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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703793
Report Date: 10/21/2021
Date Signed: 10/22/2021 08:55:14 AM

Document Has Been Signed on 10/22/2021 08:55 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:JENNY'S BOARD & CAREFACILITY NUMBER:
421703793
ADMINISTRATOR:JENNY/QUERUBEN PEREZ 98FACILITY TYPE:
735
ADDRESS:1736 N. RUSSELL AVENUETELEPHONE:
(805) 346-8571
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 6CENSUS: 6DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Jenny Perez, Administrator/LicenseeTIME COMPLETED:
03:40 PM
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On 10/21/21 at 1:40 PM, Licensing Program Analyst (LPA) Toan Luong arrived at the facility and contacted Licensee/Administrator Jenny Perez via telephone to perform a facility risk assessment. LPA conducted an unannounced on-site One Year Infectious Control Annual visit to the facility. LPA met with Administrator Jenny Perez and explained the purpose of the visit.

Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department.

The facility is an Adult Residential Facility. During the facility tour LPA advised posting CDSS PINs and have PINs readily accessible to residents, visitors, and staff. LPA recommended administrator have staff fit-tested with N95 masks. One room has beds not six feet apart. LPA advise rearranging beds to meet compliance.

LPA reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with administrator to satisfaction.

Exit interview was conducted. No deficiencies were cited. Report emailed to administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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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