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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850008
Report Date: 11/22/2021
Date Signed: 11/23/2021 10:11:32 AM

Document Has Been Signed on 11/23/2021 10:11 AM - 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:UCP WORK INC - LAKESIDE HOUSEFACILITY NUMBER:
425850008
ADMINISTRATOR:STEVEN ALMAGUERFACILITY TYPE:
735
ADDRESS:423 MONTEREY RDTELEPHONE:
(805) 739-0451
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 4CENSUS: 4DATE:
11/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Director of Residential Services Pam HolcombeTIME COMPLETED:
11:50 AM
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On 11/22/21 at 9:35 AM, Licensing Program Analyst (LPA) Toan Luong arrived at the facility and performed a facility risk assessment with facility staff. LPA conducted an unannounced on-site One Year Infectious Control Annual visit to the facility. LPA met with Director of Residential Services Pam Holcombe and Administrator Edward Maldonado and explained the purpose of the visit.

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

The facility is an Adult Residential. During the facility tour LPA observed Covid-19 signs posted throughout the facility, but CDSS PINs were not posted. LPA advise having PINs readily accessible to residents, visitors, and staff. Administrator posted CDSS PINs prior to LPA's departure. LPA advised facility to fit-test staff. Facility is awaiting test kits from company department.

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

Exit interview was conducted. No deficiencies cited and report emailed to director.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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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