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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800215
Report Date: 03/22/2022
Date Signed: 03/22/2022 01:17:12 PM

Document Has Been Signed on 03/22/2022 01:17 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:MCMILLAN RANCHFACILITY NUMBER:
425800215
ADMINISTRATOR:MARTHA MANCHAFACILITY TYPE:
735
ADDRESS:3840 ORCUTT GAREY ROADTELEPHONE:
(805) 937-2826
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 10CENSUS: 10DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Martha ManchaTIME COMPLETED:
01:30 PM
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On 03/22/22 at 12:00 p.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual visit to the facility. LPA met with Administrator Martha Mancha and explained the purpose of the visit. LPA toured the facility.

At 12:30 p.m., LPA discussed items in the Infection Control Module and noted California Department of Social Services Provider Information Notices (CDSS PINs) were only verbally communicated to residents. Moving forward, administrator will post PINs on the bulletin for resident access or inquiry. Infection Control module was addressed with administrator to satisfaction. Facility answered yes or n/a to all other items in the Infection Control Module.

LPA conducted exit interview and emailed report to the administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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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