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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800790
Report Date: 03/14/2022
Date Signed: 03/14/2022 12:20:30 PM


Document Has Been Signed on 03/14/2022 12:20 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:SUPERIOR RESIDENTIAL CARE FACILITY FOR THE ELDERLYFACILITY NUMBER:
425800790
ADMINISTRATOR:ERIC SO HUFACILITY TYPE:
740
ADDRESS:1034 DONALD WAYTELEPHONE:
(805) 937-0939
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:6CENSUS: 5DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Eric SoHu and Laarni SoHuTIME COMPLETED:
12:35 PM
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On 03/14/22 at 9:50 a.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual visit to the facility. LPA met with Administrator Laarni SoHu and Eric SoHu and explained the purpose of the visit.

LPA was screened at the entrance, and LPA toured the residential care facility for the elderly. At 11:20 a.m., LPA discussed items in the Infection Control Module and noted that the facility did not have signs posted in the facility promoting cough/sneeze etiquette, hand washing, reporting of acute respiratory illness to staff. The facility has not completed fit testing for staff. Administrator states that fit testing is difficult to obtain in the area as testing sites are located in Los Angeles which is more 120 miles away. The facility did not have California Department of Social Services Provider Information Notices (CDSS PINs) available. Administrator will have relevant PINs posted for staff, residents, and visitors. Administrator has verbally updated visitors, residents, and staff on current PINs and will provide PINs upon future requests. Infection Control module was addressed with administrator to satisfaction.

LPA conducted exit interview with administrator and emailed a copy of today's report and appeal rights to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
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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