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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850049
Report Date: 11/30/2021
Date Signed: 12/01/2021 01:50:07 PM

Document Has Been Signed on 12/01/2021 01:50 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:PROVIDENCE RESIDENTIAL HOMEFACILITY NUMBER:
425850049
ADMINISTRATOR:JEMERSON, ANALIZA V.FACILITY TYPE:
735
ADDRESS:1439 WALLIS AVENUETELEPHONE:
(805) 720-9577
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 4CENSUS: 4DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Analiza JemersonTIME COMPLETED:
03:45 PM
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At 2:22pm, on 11/30/2021, Licensing Program Analysts LPA Diaz conducted an unannounced annual inspection of the facility above.

LPA informed administrator of the reason for the visit. LPA and Administrator toured the facility. LPAs initial tour of the facility resulted in observations which were immediately addressed by the administrator and facility staff: At 2:34pm, LPA observed no hand washing signage in the kitchen. Assistant Administrator placed washing signage in the kitchen. At 2:49pm, LPA observed a 2 month expired fire extinguisher. LPA observed laundry room and laundry detergent locked in the appropriate cabinet. LPA observed clean counter tops, and adequate food in cabinets and in refrigerator. LPA also observed supply of PPE, toilet paper soap and paper towels. LPA observed all window screens to be intact.

At 2:55pm, LPA Diaz conducted Infection Control mitigation module with Administrator. Administrator was instructed to immediately search for an N95 fit testing vendor. LPA observed 1 shed with maintenance equipment unlocked in the backyard. Assistant Administrator immediately locked shed. No other corrections found in mitigation module.

Exit interview conducted and report emailed

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Arien Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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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