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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850225
Report Date: 10/26/2022
Date Signed: 10/26/2022 11:06:22 AM

Document Has Been Signed on 10/26/2022 11:06 AM - 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:FAMILY CONNECT MEMORY CARE SOLVANGFACILITY NUMBER:
425850225
ADMINISTRATOR:MAHAKIAN, LAURENFACILITY TYPE:
740
ADDRESS:659 CHALK HILL ROADTELEPHONE:
(310) 383-1877
CITY:SOLVANGSTATE: CAZIP CODE:
93463
CAPACITY: 6CENSUS: DATE:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Virginia Rodriguez, ManagerTIME COMPLETED:
11:25 AM
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On 10/26/22 at 10:00 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Virginia Rodriguez, Manager, and explained the purpose of the visit.

LPA toured the facility with the manager and observed the following: The facility has infection control signage at the front door and signage throughout the facility on handwashing and use of masks. Cough etiquette signage is not displayed. Licensee will post cough etiquette signage, take photo and send to LPA by end of day 10/27/22. Upon entry to the facility, LPA was screened. Staff are wearing masks. The facility has soap and paper towels in resident bathrooms (2). Fire extinguishers are located in the entryway, activity room, and hallway near bedroom #2. The extinguishers are fully charged and were inspected on 11/21/21.

At 10:26 am, LPA conducted the Infection Control mitigation module with the manager. No deficiencies cited.

Exit interview conducted and report emailed to the licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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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