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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445201621
Report Date: 03/09/2022
Date Signed: 03/10/2022 08:06:05 AM


Document Has Been Signed on 03/10/2022 08:06 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,
, CA



FACILITY NAME:DE UN AMORFACILITY NUMBER:
445201621
ADMINISTRATOR:FLETES, MARICELAFACILITY TYPE:
740
ADDRESS:460 EUREKA CANYON ROADTELEPHONE:
(831) 728-0303
CITY:CORRALITOSSTATE: CAZIP CODE:
95076
CAPACITY:25CENSUS: 20DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Veronica OritzTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Veronica Oritz Assistant Administrator.

LPA toured the facility inside and out. All fire exit routes were free and clear of obstructions. Sharp objects, toxins, cleaning supplies are secured. Medications are stored in a locked cabinet in the kitchen and in the medication room.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathrooms observed to be supplied with hygiene products and paper towels. Hand Washing signs posted in the bathrooms and kitchen sink areas. Hand sanitizer available to visitors and residents. LPA observed supply of Personal Protective Equipment (PPE). COVID 19 signs posted included Visitor Policy, Face Coverings Required For Entry, Cover Your Face, Stay 6 Feet Apart, Limit Family Gatherings, COVID 19 Response and We All Play A Role.

LPA reviewed the facility policies and procedures to include screening, visitation, masking, isolation and disinfecting,

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Veronia Oriz Assistance Administrator and a copy provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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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