425850049-12-5-2023-29-AS-JOLN-CY8UMU-20231205144256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850049
Report Date: 12/05/2023
Date Signed: 12/05/2023 02:44:05 PM

Document Has Been Signed on 12/05/2023 02:44 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 HOME		FACILITY NUMBER:	425850049
ADMINISTRATOR:	JEMERSON, ANALIZA V.		FACILITY TYPE:	735
ADDRESS:	1439 WALLIS AVENUE		TELEPHONE:	(805) 720-9577
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY: 4		CENSUS: 4	DATE:	12/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Analiza Jemerson, Administrator		TIME COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Jenny Olson arrived unannounced to conduct a one year required annual inspection. LPA met with Administrators and explained the reason for the visit.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The facility has a sufficient supply of non-perishable and perishable food items. Cleaning supplies and disinfectants are stored and locked in a cabinet in the garage, inaccessible to clients. Knives are stored in a locked cabinet under the sink.

Common areas: Living and dining room furniture were observed to be in good condition. At 1:00 p.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. LPA observed required postings throughout the common space. The fire extinguishers were charged and serviced 12/4/2023.

The backyard has a covered outdoor area with shade equipped with furniture for client use. No bodies of water noted. The washer and dryer are in the garage.

Restrooms: The one client restrooms was clean and sanitary and in operating condition with non-skid mat. The bathroom was sufficiently stocked with soap and paper towels. Around 1:15 p.m., the hot water temperature measured in the client kitchen between 118.8-120.1 degrees Fahrenheit.

Bedrooms: There are four (4) client rooms, which were furnished with appropriate linens and required furniture. A linen closet was located outside of the rooms, which stocked extra linens and towels.

Records: LPA reviewed client and staff records at 11:45 a.m. LPA reviewed four (4) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and needs and services plan. All files were complete. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PROVIDENCE RESIDENTIAL HOME	FACILITY NUMBER: 425850049
	VISIT DATE: 12/05/2023

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LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 3 home. The last disaster drill was conducted on 10/21/23.

Medications: Medications review began at 1:30 p.m. medications are centrally stored and locked in a cabinet in the office. Medications are labeled and checked for expiration dates. All the necessary information is properly documented on the CSMDR!

Infection Control: The facility has an infection control plan. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is adequate. The facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

LPA interviewed 2 staff at 1:40 pm. All 4 clients were at program or in the community and unable to be interviewed during the visit.

Exit interview conducted. A copy of the report was printed and emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC809 (FAS) - (06/04)

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