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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800697
Report Date: 04/19/2024
Date Signed: 04/19/2024 11:12:30 AM


Document Has Been Signed on 04/19/2024 11:12 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:MY FAMILY RESIDENTIAL CARE HOMEFACILITY NUMBER:
425800697
ADMINISTRATOR:ANNIE MENDIOLAFACILITY TYPE:
740
ADDRESS:514 W. MCELHANEY AVE.TELEPHONE:
(805) 925-7836
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 6DATE:
04/19/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Administrator Michelle TantingcoTIME COMPLETED:
11:45 AM
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 At 8:15am on 04/19/2024, Licensing Program Analyst (LPA) arrived unannounced to conduct the continuation of the annual facility inspection. LPA met with Administrator Michelle Tantingco, announced who he is and the reason for the visit.

Administrator and LPA conducted a second physical inspection of the facility as part of the continuation annual inspection. LPA noted that this is a 7 bedroom and 6 bathroom (Six single resident occupancy, and one staff room) facility with two living room areas, one dining room, a large back yard with fixed pergola that provides shade for residents, visitors, and staff. Medications are kept in a cabinet in the living room with lock on the door. Staff and Resident files are kept in a locked file cabinet in the living room number one. LPA observed at least 2 days of perishable and at lease 7 days of non perishable foods on hand for six residents and staff. LPA noted that the facilities first aide kit is complete by regulations and is located in the dining room area. LPA conducted a sample medication audit and found all Centrally Stored Medication Records (CSMR) to complete and accurate. LPA conducted a file review of staff and residents files and found all files to be compete and current (LIC602's with in 12 months for 5 of 6 residents). LPA noted that the fire extinguisher is rated in the green range. LPA tested smoke detectors and carbon monoxide detector and found them to all be operational. LPA noted that the facility was clean and in good repair. LPA noted that between the initial visit for annual inspection and the return continuation visit. Administrator replaced the hood over the stove to mitigate the oil build up that was on the old hood. LPA noted that no citations were issued as a result of the physical inspection.

Administrator and LPA conducted a full review of the annual care tools modules. LPA noted that there were no technical. violations, or citations issued as a result of the annual care tools module review. LPA noted that no violations or citations were issued as result of this annual facility inspection.

Exit interview, report read, report singed, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
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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