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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800707
Report Date: 09/22/2022
Date Signed: 09/22/2022 11:19:38 AM


Document Has Been Signed on 09/22/2022 11:19 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:CLOE AND ERICA'S BOARD & CAREFACILITY NUMBER:
425800707
ADMINISTRATOR:ALAN FLOJOFACILITY TYPE:
740
ADDRESS:1027 LAUREL CT.TELEPHONE:
(805) 937-7657
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:6CENSUS: 6DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Alan Flojo/LicenseeTIME COMPLETED:
11:15 AM
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 At 9:00am on 09/22/2022, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual infection control inspection. LPA was screened properly at the front door by staff for COIVD-19 screening protocols. LPA met with Licensee Alan Flojo announced who he was and reason for the visit.
At 9:10am Licensee and LPA conducted a tour of the facility. The facility is an eight bedroom, 3 bathroom, kitchen, two main living areas, larger outdoor covered patio with shade from pergola, and two locked storage sheds. There are six single occupancy resident rooms and two bathrooms for resident use. The other two bedrooms and bath room is designated for staff use. LPA observed more than two days of perishable and seven days of nonperishable foods. LPA observed and test fire detectors and carbon monoxide detectors to all be in working order. LPA noted that water temperature to be with in regulations parameters, not exceeding 120*f. LPA noted that all fire extinguisher were in the green load range. LPA observed the facility to be clean and free of any visible hazards and did not find any issues with the cursory tour. All staff working at the facility today were clear from the list provided by LIS. LPA observed at least a 30 day supply of PPE stored in facility closet.
At 9:45am, Licensee and LPA conduced the infection control module of the annual inspection. LPA did not find any deficiencies during the infection control module. No citations issued.

Exit interview, report singed, and report email.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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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