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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800332
Report Date: 02/23/2022
Date Signed: 02/23/2022 11:21:44 AM

Document Has Been Signed on 02/23/2022 11:21 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:FUTURES UNLIMITEDFACILITY NUMBER:
425800332
ADMINISTRATOR:PHIL WARDFACILITY TYPE:
735
ADDRESS:4505 ARAGON DRIVE #CTELEPHONE:
(805) 566-1575
CITY:CARPINTERIASTATE: CAZIP CODE:
93013
CAPACITY: 6CENSUS: 6DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Ashley HolmesTIME COMPLETED:
11:30 AM
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On 02/23/22 at 9:35 a.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual visit to the facility. LPA met with Administrator Ashley Holmes and explained the purpose of the visit.

At 10:20 a.m., LPA discussed items in the Infection Control Module and noted that staff have not been fit tested with N95. LPA emailed informational resources to administrator regarding fit testing. One bedroom has beds less than 6 feet apart side by side. LPA made recommendation to rotate one bed to the corner of the room to have beds 3 feet apart head-to-toe orientation. LPA made recommendation to obtain additional N95 masks as LPA counted 2 boxes of 20 count BYD N95 masks. Infection Control module was addressed with administrator to satisfaction. Facility answered yes or n/a to all other items in the Infection Control Module.

No deficiency was issued. LPA conducted exit interview and emailed report and appeal rights to the administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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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