<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850083
Report Date: 12/20/2021
Date Signed: 12/20/2021 04:48:56 PM

Document Has Been Signed on 12/20/2021 04:48 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:DOCTOR'S RESIDENTIAL CARE FACILITY #2FACILITY NUMBER:
425850083
ADMINISTRATOR:GILL, NATASHAFACILITY TYPE:
735
ADDRESS:2412 CESAR E CHAVEZ DRTELEPHONE:
(702) 858-4266
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 4CENSUS: 4DATE:
12/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nathaly Chavez, StaffTIME COMPLETED:
12:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/20/21 at 10:00 AM, Licensing Program Analyst (LPA) Toan Luong conducted a facility risk assessment with Administrator Natasha Gill. LPA conducted an unannounced on-site One Year Infectious Control Annual visit to the facility. LPA met with Staff Ana Lainez and Staff Nathaly Chavez and explained the purpose of the visit.

Staff took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department.

The facility is an Adult Residential Facility. During the facility tour LPA advised posting of signs encouraging social distancing, hand washing, and cough etiquette. LPA advise having CDSS PINs readily accessible to residents, visitors, and staff. LPA advised facility to fit-test staff. Facility did not have a 30-day supply of PPE. LPA observed 5 boxes of 20 count N95 masks, three boxes medium size gloves. Facility had an adequate supply of other PPE. LPA inquired if licensee has an additional facility in which supplies may be obtained from without affecting 30-day supply or to request additional supplies from TCRC or CCLD. Facility has one bedroom with beds not 6 feet apart, but additional bed is unused. LPA observed thermostat having low battery and recommended replacement to maintain temperature within regulation.

LPA reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with Staff Nathaly to satisfaction.

Exit interview was conducted. No deficiencies cited and report emailed to administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1