<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802105
Report Date: 04/27/2023
Date Signed: 04/27/2023 12:59:35 PM

Document Has Been Signed on 04/27/2023 12:59 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PEOPLE'S CARE LAKE MARIEFACILITY NUMBER:
425802105
ADMINISTRATOR:REA BONNER HALLMONFACILITY TYPE:
735
ADDRESS:2186 LAKE MARIE DRTELEPHONE:
(805) 314-2093
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 4CENSUS: 4DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rea Bonner Hallmon, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/27/2023 at 9:00am Licensing Program Analysts (LPAs) Brian Phillips and Mark Jeffries arrived at the facility to conduct a required annual 1-year site inspection. The LPAs met with Administrator Rea Bonner Hallmon and explained the reason for the visit. The LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is compliant with Title 22 Regulations. This is an Adult Residential Facility with fire clearance for 4 ambulatory residents.

Kitchen: The kitchen area was observed at 9:15am. The facility has a sufficient supply of non-perishable and perishable food items as well as utensils for all clients. Cleaning supplies and disinfectants are stored inaccessible to clients. Knives are stored in a locked safe. The stove and dishwasher are in operating condition.

Common areas: All furniture in the facility was observed to be in good condition. At 9:45am, smoke detectors and carbon monoxide detectors were tested and operational. The LPAs observed required postings throughout the common space. The fire extinguishers were charged and serviced. A 2nd non-operational dishwasher will be removed within the week according to the administrator. The washer and dryer are in the laundry room. Each resident has adequate supply of fresh linen located in their bedroom closet(s).

Restrooms: The two client restrooms were clean, sanitary, and in operating condition with nonskid surfaces. The restrooms were sufficiently stocked with soap and paper towels. At 9:30am, the hot water temperature measured in the hallway restroom was within temperature regulations, however the water pressure for the hot water faucet was not adequate. The LPAs informed the administrator who immediately began to make arrangements to correct the hot water pressure in the hallway restroom sink.

The backyard has a covered outdoor area equipped with furniture for client use. The side gate was audio egress self-closing and latched. The garage is locked. Residents have a designated smoking section located in the backyard with an appropriate waste disposal for cigarettes. Contd. on LIC809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PEOPLE'S CARE LAKE MARIE
FACILITY NUMBER: 425802105
VISIT DATE: 04/27/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 At 11:15am LPA's and Administrator reviewed all questions in all modules of the inspection care tool. All questions were in the affirmed yes or not applicable. There were no violations, technical or citations found during the review of the care tool and its modules. There were no citations, violations or technical issued as a result of the annual inspection.

Exit interview, report read, report signed and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2