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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850081
Report Date: 12/21/2021
Date Signed: 12/21/2021 04:09:55 PM

Document Has Been Signed on 12/21/2021 04:09 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:STADIUM PLACE HOMEFACILITY NUMBER:
425850081
ADMINISTRATOR:ASCALON, CLAIRE RNFACILITY TYPE:
734
ADDRESS:961 STADIUM PLACETELEPHONE:
(650) 580-8750
CITY:SOLVANGSTATE: CAZIP CODE:
93463
CAPACITY: 5CENSUS: 4DATE:
12/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Cindy Baker, Administrator, Donna Pieprzycki, RN Consultant, Claire Ascalon, RNTIME COMPLETED:
02:50 PM
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At 1:00 pm, on 12/21/2021, Licensing Program Analysts (LPAs) Darlene Chavez and Jenny Olson conducted an unannounced annual infection control inspection of the facility above. Attendees also included Tracy Jackson and Paige Coffee, Tri-Counties Regional Center (TCRC), and Steve Reed, Department of Developmental Services (DDS). LPAs met with Cindy Baker, Administrator, Donna Pieprzycki, RN Consultant, Claire Ascalon, RN, and informed administrator of the reason for the visit. LPAs, TCRC, DDS, and administrator toured the facility.

LPA’s initial tour of the facility resulted in observations which were immediately corrected. LPAs were screened upon entry to the facility by staff. At 1:00 pm, LPA Chavez observed a “No Visitor” sign at the front door. Administrator replaced signage to allow visitors. At 1:15 pm, LPA Chavez observed that Bedrooms #1 and #5 were missing screens or screen doors on the full-length doors leading to the exterior. Administrator will install screens to cover the doors. Kitchen water temperature was at 119 F, bathroom #1 at 108 F, and bathroom #2 at 108 F, and guest bathroom at 110 F. At 1:55 pm, LPA Chavez observed that the facility has an 8.5x11” CCLD reporting poster. Administrator will print a 20”x26” color poster and place in facility.

At 1:38 pm, LPA Chavez conducted the Infection Control mitigation module with administrator. No deficiencies noted.

Exit interview conducted and report emailed to the administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2021
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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