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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800650
Report Date: 02/24/2023
Date Signed: 02/24/2023 02:51:41 PM

Document Has Been Signed on 02/24/2023 02:51 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: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:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Baron GrahamTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 9:50 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Baron Graham and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and functioned properly. The fire extinguisher appeared fully charged and was last inspected 2/13/23.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives are stored in the locked staff room/office and cleaning supplies are locked in the garage. BEDROOMS: The LPA observed one shared client bedroom and two single-occupancy client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. One client room is in the process of being cleaned out of excess personal items. RESTROOMS: Restrooms are clean and sanitary and in operating condition. Water temperature was 106.2*F. COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings. The backyard patio is equipped with furniture for clients' use.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. Staff were observed wearing masks. There was an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID.

No deficiencies observed. Exit interview conducted. Report emailed to Administrator.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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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