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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800926
Report Date: 03/23/2023
Date Signed: 03/23/2023 03:34:24 PM


Document Has Been Signed on 03/23/2023 03:34 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:TINA'S GENTLE CARE HOMES IFACILITY NUMBER:
425800926
ADMINISTRATOR:ROBERTS, VALENTINAFACILITY TYPE:
740
ADDRESS:1625 ROWLAND DR.TELEPHONE:
(805) 925-0748
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 2DATE:
03/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Valentina Roberts, Administrator/LicenseeTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jenny Olson conducted an unannounced Annual visit to the facility above. LPA met with Valentina Roberts at 10:45 AM, and explained the purpose of the visit. Administrator stated there are 2 residents currently living in the facility.

The facility has 4 bedroom's and 2 bathrooms. 2 resident bedrooms are occupied by single residents. LPA observed all necessary postings in the hall to the left of the entrance.

LPA toured the entire inside and outside of the facility with Administrator. There is ample room outside for residents to be outdoors with a table, chairs and awning for shade. LPA observed the refrigerator, cabinets, microwave, and oven to be clean with enough food for residents. Medications were observed locked and secured in a cabinet located to the upper right of the kitchen sink. LPA observed knives and sharps locked in a drawer. LPA observed chemicals to be locked in the garage. At 12:30 PM LPA tested the water temperature and observed it was at 115.1 degrees F. At 12:40 PM LPA tested the fire/carbon monoxide detector and observed them to be working and operational. LPA didn't observe any violations and observed the facility to be clean and in good repair with all passageways and exits to be free and clear of debris and obstacles.

Around 11 AM LPA reviewed facility staff files for completeness. Around 11:45 AM LPA and Staff conducted a full CARE Tool Facility Inspection. Around 12:45 PM LPA conducted a cursory medication audit and reviewed MARs and medications paperwork. Around 1:30 PM LPA reviewed facility resident records for completeness. Around 2 PM LPA observed a fire extinguisher charged and last inspected on 2/7/23. Around 2:15 PM LPA Interviewed 2 staff and 2 residents who were present.

Exit Interview conducted, a copy for the report was issued to facility.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
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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