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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800650
Report Date: 04/19/2022
Date Signed: 04/19/2022 02:01:33 PM

Document Has Been Signed on 04/19/2022 02:01 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:GLOUCESTER HOUSEFACILITY NUMBER:
565800650
ADMINISTRATOR:BARON GRAHAMFACILITY TYPE:
735
ADDRESS:771 JOYCE DRIVETELEPHONE:
(805) 271-5086
CITY:PORT HUENEMESTATE: CAZIP CODE:
93041
CAPACITY: 4CENSUS: 4DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Baron GrahamTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required
annual visit at 10:40 a.m. This annual had a specific emphasis on infection control practices and procedures.
The LPA met with Administrators Baron Graham and discussed the reason for the visit. The LPA, along with Administrator, toured the physical plant areas inside and outside at 11:10 a.m. to ensure there are no health and safety hazards. Entrance interview conducted.

BEDROOMS: The LPA observed the clients bedrooms, which were furnished appropriately with clean
linens, appropriate furnishings and sufficient lighting. There are four (4) total bedrooms – three (3) bedrooms
are client rooms and one (1) room is for staff.

RESTROOMS: Two (2) restrooms where observed to be clean and sanitary and in operating
condition. The bathrooms and showers were also observed to have grab bars and non-skid surfaces. The
LPA observed sufficient amounts of soap and paper products in each restroom, as well as hand washing
posters. Water temperature was tested and was within normal ranges.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good
condition. At the time of the visit, common seating area and dining room furniture was observed to be in good
condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the
required postings in the common hallway. Fire extinguishers were observed to be serviced within the last
year. Smoke detectors and carbon monoxide was observed to be in operable condition at the time of visit.
The backyard has a covered area equipped with furniture for client use. There are no bodies of water
noted. Garage was observed to be locked and contained locked storage cabinet for laundry supplies.
Medication was observed to be locked and contained at least a 30-day supply.

Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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 2
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: GLOUCESTER HOUSE
FACILITY NUMBER: 565800650
VISIT DATE: 04/19/2022
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KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable
and non-perishable food. Water temperature was observed to be within normal limits. All knives and cleaning
supplies were observed to be locked and properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s
infection control practices at 11:15 a.m. There is one (1) entry into the facility. Upon entry, the facility has a
central point for symptom screening. LPA noted that the facility is allowing visitors for outdoor
visitation only. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and is able to
obtain more if needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to
designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and
procedures as it pertains to infection control are adequate.

No citations were issued today's visit. Exit interview conducted. Copy of the report provided to Admin via
email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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