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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850004
Report Date: 12/13/2021
Date Signed: 12/13/2021 12:24:36 PM

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 #1FACILITY NUMBER:
425850004
ADMINISTRATOR:KAMTO, YOLANDE KONGUEP T.FACILITY TYPE:
740
ADDRESS:958 E TUNNELL STTELEPHONE:
(805) 922-7670
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 4DATE:
12/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrators Yolande Kamto and Cheryll EstacioTIME COMPLETED:
12:30 PM
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On 12/13/21 at 9:45 AM, Licensing Program Analyst (LPA) Toan Luong contacted the facility and performed a risk assessment with staff. LPA conducted an unannounced on-site One Year Infectious Control Annual visit to the facility. An administrator nor backup was not present until 11:00 AM. LPA met with Administrators Yolande Kamto and Cheryll Estacio and explained the purpose of the visit.

LPA toured the facility. The facility has submitted a mitigation plan to the department.

The facility is a Residential Facility for the Elderly. During the facility tour LPA observed Covid-19 signs posted throughout the facility, but did not have a visitation policy consistent with CCLD. LPA advised administrator update visitation policy to allow in-person visitation. Facility Administrator updated signage prior to LPA's departure. LPA advise administrator to post latest CDSS PINs. LPA advised facility to fit-test staff. Facility did not have a 30-day supply of PPE. LPA observed one sandwich sized ziplock bag containing an estimated eight N95 masks. Facility administrator will obtain additional PPE.

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

Exit interview was conducted. No deficiencies cited, and report emailed to administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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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