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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850032
Report Date: 08/03/2022
Date Signed: 08/03/2022 12:46:08 PM

Document Has Been Signed on 08/03/2022 12:46 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:VALLEY HAVENFACILITY NUMBER:
425850032
ADMINISTRATOR:OWENS, COLODIAFACILITY TYPE:
775
ADDRESS:2800 HARRIS GRADE RDTELEPHONE:
(805) 733-9459
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 30CENSUS: 7DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Colodia Owens, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Olson conducted an on-site 1 year infection control annual visit to the facility above on 08/03/2022 at 10:40 AM. LPA met with Colodia Owens, Administrator and explained the purpose of the visit.

LPA took a physical plant tour of the inside and outside of the facility with Administrator.
The facility has an entry point where everyone entering completes sign-in and temperature check for all staff, clients, and visitors wanting to come into the facility. All documentation is kept on file.

The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Administrator is in charge of infection control and provides training and education to staff, clients and visitors.

If any suspected or confirmed cases of Covid-19 are found inside the facility a staff will use PPE supplies that will be located right outside of the isolation room when required. Facility has a 30 day supply of PPE on hand. The facility has proper cleaning and disinfectant policies. Facility has a plan in place for when and whom to notify in an outbreak or other emergencies. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. The facility ensures proper cleaning is done on frequently touched surfaces at least once a day. Sinks were well stocked with soap, paper towels and hand washing signs. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. No deficiencies observed during the visit and all infection control protocols are implemented and are being followed. Exit interview completed and copy of report emailed to Administrator/ Licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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