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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801838
Report Date: 02/04/2025
Date Signed: 02/04/2025 01:11:10 PM

Document Has Been Signed on 02/04/2025 01:11 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:A SPLENDID LIVING, RCFEFACILITY NUMBER:
425801838
ADMINISTRATOR/
DIRECTOR:
VALENTINA ROBERTSFACILITY TYPE:
740
ADDRESS:2305 CABALLERO LANETELEPHONE:
(805) 714-9063
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
02/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Administrator, Vanetina RobertsTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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At 8:00am on 02/04/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with Administrator, Vanetina Roberts, announced who he is and the reason for the visit. LPA reviewed staff roster and cleared all 3 care staff that were working at this facility. LPA conducted full Staff and Resident file reviews, LPA reviewed facilities Emergency Disaster Plan, Infection Control Plan and Medication Administration Records (MAR) and Centrally Stored Medication Records (CSMR). LPA reviewed facilities Plan of Operation (POA) including Dementia requirements and Bedridden requirements as outline in facilities POA. LPA noted that no citations or violations were noted during the documentation reviews.
Administrator and LPA conducted a facility tour LPA noted that the facility is a 6 bedroom, single resident occupancy, 3 shared bathrooms, two living rooms, 2 dining rooms, a kitchen. There is a large back yard with a room for seating and a covered patio for shade so that residents have access to outside activities and visits. LPA noted that the medications are locked in a medication cabinet located in living room 1. There is a regulations completed !st Aide kit located in the medication cart. LPA observed at least 2 days of perishable foods and at least 7 days of nonperishable food for 6 residents and staff. LPA observed emergency food supply in the garage for more than 72 hours of supplies. LPA noted that the are fire extinguishers that are primed and in the green reading, LPA noted that all rooms have duel, smoke and carbon monoxide detectors that are hard wired and battery. LPA noted that the facility has a sprinkler system with a fire pull located in the hallway. LPA observed that water pressure to the sprinkler system to be at 77 lbs. which is located at the front of the facility. LPA noted that all exits were free of obstructions and obstacles. LPA noted that the facility is clean and in good repair. LPA noted that no citations or violations were noted during the physical tour of the facility.
Administrator and LPA conducted a full review of the annual care tools modules. LPA noted that there were no citations or violations during the care tools modules review. LPA noted that there are no citations of violations as a result of the facilities full annual inspection review.

Exit interview, report read, and report provided.
Kelly BurleyTELEPHONE: (805) 562-0413
Mark JeffriesTELEPHONE: (805)562-0400
DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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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