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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850042
Report Date: 02/01/2022
Date Signed: 02/01/2022 02:15:33 PM

Document Has Been Signed on 02/01/2022 02:15 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:NANCY'S RESIDENTIAL CAREFACILITY NUMBER:
425850042
ADMINISTRATOR:SOLORIO, NANCYFACILITY TYPE:
735
ADDRESS:1043 NORTH E PLACETELEPHONE:
(805) 868-5000
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 4CENSUS: 4DATE:
02/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Nancy SolorioTIME COMPLETED:
02:20 PM
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On 02/01/22 at 12:30 p.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Annual visit to the facility. LPA with Administrator Nancy Solorio and explained the purpose of the visit. The facility is an Adult Residential Facility with funding from Tri-Counties Regional Center (TCRC).

At 1:00 p.m., LPA discussed items in the Infection Control Module and noted that staff have not been fit tested with N95. Administrator has contacted TCRC for additional guidance as providers were not available within 100 mile proximity. Infection Control module was addressed with administrator to satisfaction. Facility answered yes or n/a to all other items in the Infection Control Module.
LPA did not observe any deficiencies.

LPA conducted exit interview and emailed report to the administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2022
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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