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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850082
Report Date: 02/22/2022
Date Signed: 02/22/2022 12:32:41 PM

Document Has Been Signed on 02/22/2022 12:32 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:MOUNTAIN RIDGE HOME CORPFACILITY NUMBER:
425850082
ADMINISTRATOR:BAKER, CINDYFACILITY TYPE:
734
ADDRESS:3271 OLD HIGHWAY 246TELEPHONE:
(650) 267-9482
CITY:SANTA YNEZSTATE: CAZIP CODE:
93460
CAPACITY: 5CENSUS: 5DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Cindy BakerTIME COMPLETED:
12:45 PM
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On 02/22/2022 at 10:50 a.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual Visit. LPA met Tri-Counties Regional Center Quality Assurance Specialist Tracy Jackson and Administrator Cindy Baker at the facility and explained the purpose of the visit. LPA toured the facility.

At 11:30 a.m., LPA opened the Infection Control Tool Module and discussed items in the infection control. All items were answered yes or not applicable. Infection Control Module was address with administrator to satisfaction.
At 12:15 p.m., LPA received updated email address and mobile contact information from the administrator.

No deficiency was issued. LPA conducted exit interview and emailed appeal rights and report to administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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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