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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800067
Report Date: 06/15/2021
Date Signed: 06/15/2021 04:28:09 PM

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:MARIA'S GUEST HOMEFACILITY NUMBER:
425800067
ADMINISTRATOR:GERARDO SANCHEZFACILITY TYPE:
740
ADDRESS:516 NORTH MARY DRIVETELEPHONE:
(805) 925-4632
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 3DATE:
06/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:GERARDO SANCHEZTIME COMPLETED:
11:40 AM
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At 9:05am, on 06/15/2021, Licensing Program Analysts LPA Arien Diaz conducted an unannounced annual inspection of the facility above. LPA informed administrator of the reason for the visit. LPA and Administrator toured the facility. LPA initial tour of the facility resulted in observations which were immediately addressed by the administrator and facility staff: At 9:09am, LPA observed sign in sheet near the kitchen and not at the front entrance. Administrator moved sign in sheet to the front entrance. At 9:17am, LPA observed no hand washing poster in the Kitchen. At 9:23am, LPA observed dog droppings in the backyard patio. LPA observed 2 window screens with holes and 1 window screen was missing from a bedroom. LPA observed laundry room and laundry detergent exposed on top of the washer. Administrator, immediately locked detergent in the appropriate cabinet. LPA observed clean counter tops, and adequate food in cabinets and in refrigerator. LPA also observed supply of PPE, toilet paper soap and paper towels.

At 9:53am, LPA Diaz conducted Infection Control mitigation module with Administrator. Administrator was instructed to immediately search for an N95 fit testing vendor. LPA observed 2 sheds with maintenance equipment unlocked in the backyard. Administrator will have sheds locked today on 6/15/21. No other corrections found in mitigation module.

Exit interview conducted and report given
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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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