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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850267
Report Date: 12/01/2022
Date Signed: 12/01/2022 03:51:18 PM

Document Has Been Signed on 12/01/2022 03:51 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:SOLORIO RESIDENTIAL CAREFACILITY NUMBER:
425850267
ADMINISTRATOR:SOLORO, SYLVIA RAEFACILITY TYPE:
735
ADDRESS:612 N D STREETTELEPHONE:
(805) 291-1549
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 4CENSUS: 0DATE:
12/01/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Sylvia Rae Solorio, Administrator/LicenseeTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Olson conducted an announced pre-licensing visit. LPA was accompanied by Tracy Jackson, Quality Assurance Specialist (QAS) for Tri-Counties Regional Center (via Facetime). LPA and QAS met with Administrator/Licensee Sylivia Rae Solorio. This is a new facility. Component III was conducted in conjunction with this pre-licensing visit.

The facility is a one story. A physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for 4 clients, 2 non-ambulatory residents.

Applicant/Administrator took LPA on a plant tour of the inside and outside of the one story facility and the following is noted:


Medications: There is a locked cupboard in the Kitchen for the medication.
Physical Plant: The facility is a 4 bedroom, 2 bathroom home with a kitchen, dining room/living room, and laundry room. Facility is clean, sanitary and in good repair. Indoor areas, outdoor porch, and backyard are free of obstructions. The facility does not have any pools or bodies of water. The facility does not store or allow firearms or ammunition to be stored at the facility. Any dangerous products/tools will be stored in locked shed, locked cupboards in the laundry room, kitchen, or storage area. All windows screens are clean and in good repair. Facility temperature is between 68-85 degrees. There is no fireplace. Smoke and carbon monoxide detectors are hard wired and were tested and operating properly throughout the facility.
Bedrooms: The facility has one staff bedroom and three resident bedrooms and two bathrooms for single and double occupancy. Rooms 1 and 2 are single occupancy, Room 3 is double occupancy. Bedrooms have beds for each resident with mattress, mattress pads, box springs and pillows which are clean and in good repair. Mattresses and pillows are flame-retardant. The rooms have dressers and plenty of closet space for residents. The rooms are furnished with chairs and proper lighting with lamps are in each room for clients.
Continued on 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SOLORIO RESIDENTIAL CARE
FACILITY NUMBER: 425850267
VISIT DATE: 12/01/2022
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Supplies: The facility has a sufficient supply of resident personal hygiene supplies, clean linens, towels and wash clothes. The supply of linens is sufficient for changing weekly or more if needed.
Operational Requirements: The facility has a fire clearance, plan of operation, shaded outdoor area and bond for handling clients cash resources. The water in the kitchen was 114.1 degrees and the water in the clients bathroom (bathroom 1) was 115.2 degrees, and bathroom 2 was 118.8 degrees which meets regulation requirement.
Food Service: Dining room is near kitchen, Refrigerator and freezer are clean and large enough for the storage of at least two days of perishable food. Freezer is -3 degrees Fahrenheit and refrigerator was at 35 degrees which meets regulation requirements. A seven day supply of non-perishable food is present in the other facility. A three day supply of perishables are present. There are sufficient amounts of tableware, tables, dishes, and utensils. There are sufficient amounts of equipment for the storage, preparation and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. There is a sample menu with times for all meals and snacks.
Records: The facility has confidential storage for personnel and resident records, they will be kept on shelves in locked kitchen area.
Administration: The facility has emergency plan and phone numbers posted, Residents rights, Facility visiting policy, Licensing Complaint Poster is posted in a prominent place at the facility.
Activities: There is an outdoor space with a shaded areas and furnished for outdoor use. There is at least one common room available for residents and visitors.
Miscellaneous: The facility has a current first aid manual with a first aid kit and all required supplies are present. There is working equipment for laundry. There is space for clean linen storage and separate space for soiled linen. The facility has an operating telephone available for residents use. The facility has a fire extinguisher hanging on the wall between the kitchen and the front door with a tag stating it was serviced on 10/14/22. Emergency lighting and supplies to include flashlights with batteries, emergency food supply and water is available for emergency use.

No citations issued on the pre-licensing visit.

Exit interview conducted, copy of report emailed to Applicant.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC809 (FAS) - (06/04)
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