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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802130
Report Date: 04/17/2024
Date Signed: 04/19/2024 05:04:11 PM

Document Has Been Signed on 04/19/2024 05:04 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:DOCTOR'S RESIDENTIAL CARE FACILITYFACILITY NUMBER:
425802130
ADMINISTRATOR/
DIRECTOR:
GILL, NATASHAFACILITY TYPE:
735
ADDRESS:925 W. CLARENCE CT.TELEPHONE:
(805) 623-5490
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 4CENSUS: 3DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:03 AM
MET WITH:Sarita Hidalgo - Care StaffTIME VISIT/
INSPECTION COMPLETED:
11:04 AM
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At 8:00am on 04/17/2024, Licensing Program Analyst's (LPA's) Rankin and Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA's were met with by two care providers (S1 and S2) who were both cleared through Guardian. S1 contacted Administrator by phone, LPA Jeffries confirmed with Administrator that S3 would be coming to the facility to review annual facility inspection and sign inspection report. Administrator is out of town on day of annual inspection.

This facility is a 3 bedroom 3 bathroom open living room kitchen area, den and staff office. Medications are located in office area. Client and Staff files are secure in the locked staff office LPA noted rooms for clients were clean with required furnishings per regulations. LPA noted that there was enough food for four clients and staff for 2 days of perishables and 7 days of non-perishable foods. Carbon Monoxide and fire alarm were tested and in working order. Fire clearance is being adhered to and fire extinguisher is noted in green charged level, all doors and exits were free and clear of obstacle and debris. LPA noticed there is a backyard for clients to use which had chairs and shade for clients, visitors and staff. Lighting in kitchen area is being updated for better lighting in the kitchen and living room area. LPA's conducted a sample review of staff and client files. All staff and client files were in line with regulation standards. LPA's conducted a sample medication audit. LPA's noted that the Centrally Stored Medication Records (CDMR) accurate and complete.

LPA observed clients before they left for program, there were being assisted with daily needs. LPA's and S3 conducted a full review of the care tools modules, LPA's noted that no citations were issued as a result of the full annual care tools review. LPA's noted that no citations were issued on this annual facility inspection.

Exit interview, report read, and report provided.


SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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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