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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801591
Report Date: 09/08/2022
Date Signed: 09/08/2022 03:09:31 PM

Document Has Been Signed on 09/08/2022 03:09 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:DIVERSITY HOUSEFACILITY NUMBER:
425801591
ADMINISTRATOR:CHARLES BARNESFACILITY TYPE:
735
ADDRESS:4913 PLEASANT PLACETELEPHONE:
(805) 934-9888
CITY:ORCUTTSTATE: CAZIP CODE:
93455
CAPACITY: 4CENSUS: 3DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Administrator/ Charles BarnesTIME COMPLETED:
02:01 PM
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 At 11:00am on 09/08/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct an annual infection control inspection. LPA met with Administrator Charles Barns and announced who he was and the reason for the visit.

At 11:15am Administrator and LPA took a cursory tour of the facility. The facility is a 5 bedroom, (3 residents have single rooms, 1 staff room) 3 bath, kitchen, dining room, 2 living rooms, 1 Med room (where medications are locked), and one office/craft room. LPA observed that all exits in the facility are clear of obstruction, all fire alarm and carbon monoxide detectors are functioning properly. LPA observed a 2-day supply of perishables and a 7-day supply of nonperishable foods. LPA observed appropriate amount of PPE supply at the facility. LPA noted that outside in the back yard there is currently demolition of pool and spa that is cordoned off with yellow tape, demolition is expected to end by October 2022, to be replaced with grass. LPA did not observe any noticeable hazards during this tour.

At 11:45am Administrator and LPA conducted the infection control module portion of the annual inspection. LPA noted that there were no deficiencies cited at this time.

Exit interview, report signed, and report emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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