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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802138
Report Date: 09/13/2021
Date Signed: 09/13/2021 12:12:43 PM

Document Has Been Signed on 09/13/2021 12:12 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:TELECARE AGNES AVENUEFACILITY NUMBER:
425802138
ADMINISTRATOR:PHILLIP JONESFACILITY TYPE:
772
ADDRESS:116 AGNES AVENUETELEPHONE:
(805) 457-3724
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 10CENSUS: 5DATE:
09/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Phillip Jones, AdministratorTIME COMPLETED:
12:15 PM
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On 9/13/21 at 10:40 AM, Licensing Program Analyst (LPA) Toan Luong contacted Administrator Phillip Jones to perform a facility risk assessment. LPA conducted an unannounced on-site One Year Infectious Control Annual visit to the facility. LPA met with Administrator Phillip Jones and explained the purpose of the visit.

Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department.

The facility is a Social Rehabilitation Facility. During the facility tour, LPA advised administrator to post CDSS PINs and have PINs readily accessible to residents, visitors, and staff. LPA recommended administrator update visitor policy sign at entrance. Four out of five room have beds at least 6 feet apart or 3 feet apart with head-to-toe orientation. LPA recommended rearranging beds in the 5th room to meet the requirement.

LPA reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with Administrator to satisfaction.

Exit interview was conducted. No deficiencies were cited. Report emailed to Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2021
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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