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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850003
Report Date: 12/28/2021
Date Signed: 12/28/2021 07:51:49 PM

Document Has Been Signed on 12/28/2021 07:51 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:YOKAM'S RCFE #2FACILITY NUMBER:
425850003
ADMINISTRATOR:KAMTO, YOLANDE KONGUEP T.FACILITY TYPE:
740
ADDRESS:502 N RANCH STTELEPHONE:
(805) 349-0604
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 6CENSUS: 2DATE:
12/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator Cheryll AteTIME COMPLETED:
05:00 PM
NARRATIVE
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On 12/28/21 Licensing Program Analysts (LPA) Diaz conducted a Case Management visit. LPA met with Administrator Cheryll Ate.

While touring the exterior of the facility, LPA observed two window screens that were torn, damaged and needed to be replaced. Inside the facility LPA observed a resident's bathroom with a broken light switch that needed to be repaired or replaced. LPA also observed malfunctioning light bulbs in the same bathroom.

Report reviewed and printed, exit interview conducted, deficiencies cited (on LIC809-D).
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Arien Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2021
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
Document Has Been Signed on 12/28/2021 07:51 PM - It Cannot Be Edited


Created By: Arien Diaz On 12/28/2021 at 04:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: YOKAM'S RCFE #2
FACILITY NUMBER: 425850003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2021
Section Cited

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87303(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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LPA observed bathroom light switch and light bulbs in need of repair. LPA observed multiple torn and broken window screens
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Arien Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2021


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