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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802105
Report Date: 06/09/2022
Date Signed: 06/09/2022 04:56:36 PM


Document Has Been Signed on 06/09/2022 04:56 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:PEOPLE'S CARE LAKE MARIEFACILITY NUMBER:
425802105
ADMINISTRATOR:MARIA DRUMMONDFACILITY TYPE:
735
ADDRESS:2186 LAKE MARIE DRTELEPHONE:
(805) 314-2093
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:4CENSUS: 4DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Richard Rubio/Dist. ManagerTIME COMPLETED:
05:30 PM
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At 1:00pm on 06/09/2022, Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility to conduct an annual infection control inspection. LPA also conducted a 10 day initial investigation during this visit. Investigation portion conducted prior to infection control annual.
LPA and District Manager and Intern District Manger conducted the infection control module of the annual inspection, no deficiencies were noted during the infection control module.
Administrators took LPA on a physical plant tour of the facility.The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire, and temperature screening of all staff, residents returning from an outing, and visitors requesting entry into the facility. The entry station has PPE, masks, hand sanitizer with a thermometer. The facility has a large living room area. The kitchen area has a small dining area with locks on cupboards and drawers, there is a butler pantry adjacent to the kitchen. There are 4 individual client rooms, and three client restrooms, LPA did observe soap and paper towels at each restroom sink.. Medication room is towards the back of the facility and is locked at all times. There is a recreation room towards the back of the facility. The door that leads to the garage in the back of the facility is locked at all times. LPA did not observe any regulation violations during the summary walk through with the district managers.

Exit interview, Report signed and copy provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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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