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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850081
Report Date: 12/21/2022
Date Signed: 12/21/2022 12:38:45 PM

Document Has Been Signed on 12/21/2022 12:38 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:CINDY BAKERFACILITY TYPE:
734
ADDRESS:961 STADIUM PLACETELEPHONE:
(805) 691-9036
CITY:SOLVANGSTATE: CAZIP CODE:
93463
CAPACITY: 5CENSUS: 5DATE:
12/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Donna Pieprzycki, RN ConsultantTIME COMPLETED:
12:50 PM
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On 12/21/22 at 10:53 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Staff #1 (S1) and explained the purpose of the visit. At 11:40 am, Donna Pieprzycki, RN Consultant, arrived at the facility, and LPA explained the purpose of the visit.

LPA toured the facility with S1 and observed the following: The facility has infection control signage at the front entrance and throughout the facility on handwashing, cough etiquette and use of masks. Staff are wearing masks. The facility has soap and paper towels in resident bathrooms (2). Fire extinguishers (2) are located near the nurses’ station and in the hall leading to the garage. The extinguishers are fully charged and were inspected on 12/7/22 and 12/8/22 respectively. The door leading from the hall to the garage is unlocked and can only be locked from inside the facility. The garage has ten gallon size bottles of cleaning supplies and a storage unit of cleaning supplies that was unlocked. Staff immediately secured these items in the locked shed in the backyard. Licensee will secure the internal garage door so that residents cannot access these items, take a video, and send to LPA by end of day 12/22/22. The facility has a minimum seven-day supply of non-perishables and two-day supply of perishables. The entrance to the facility has a “No Visitor” sign. LPA educated staff on the fact that visitors must be allowed, and the entrance has other applicable signage regarding visitor guidance, and requested staff to remove the No Visitor sign which staff did so immediately.

At 12:07 pm, LPA conducted the Infection Control mitigation module with the nurse consultant. No deficiencies cited.

Exit interview conducted and the report emailed to the administrator and nurse consultant.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2022
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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