<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802000
Report Date: 02/25/2022
Date Signed: 02/25/2022 02:14:32 PM

Document Has Been Signed on 02/25/2022 02:14 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,
, CA
FACILITY NAME:DREAM HAVEN OF SANTA PAULAFACILITY NUMBER:
565802000
ADMINISTRATOR:GRACE CATABAYFACILITY TYPE:
740
ADDRESS:404 E. MAIN STREETTELEPHONE:
(805) 420-9605
CITY:SANTA PAULASTATE: CAZIP CODE:
93060
CAPACITY: 6CENSUS: 5DATE:
02/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Grace CatabayTIME COMPLETED:
02:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Required 1-Year inspection. This annual had a specific emphasis on infection control practices and procedures. LPA met with Licensee/Administrator Grace Catabay at 1:12PM. Entrance interview conducted.

The LPA, along with Licensee, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility compliance with Title 22 Regulations. The facility consists of six resident bedrooms, common living area, dining room, kitchen, two full bathrooms for resident use, one staff bedroom and one and a half staff bathrooms. All indoor and outdoor passages were free of obstruction. The facility had a comfortable temperature throughout the visit.

KITCHEN/FOOD SERVICE AREA: The facility had a sufficient supply of 2-day perishable food and 7-day non-perishable food. Knives and other sharp utensils are stored in a locked drawer.

Medications were locked and centrally stored in the hall closet. Cleaning supplies are stored in the locked laundry room.

COMMON AREAS: The living room areas and dining areas are furnished appropriately. The smoke alarm and carbon monoxide detectors were tested at 2:05 PM and were operational. The fire extinguisher is fully charged and purchased on 11/21/2021. The backyard area is enclosed with a self-latching gate and outdoor activity space.

BATHROOMS: There are two common full bathrooms. The bathrooms were observed to be safe and sanitary with grab bars and non-skid mats and a supply of toilet paper, soap and paper towels.
Report Continued on LIC 809-C
SUPERVISORS NAME:
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: DREAM HAVEN OF SANTA PAULA
FACILITY NUMBER: 565802000
VISIT DATE: 02/25/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
BEDROOMS: There are six resident bedrooms that were properly furnished at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and hand sanitization. LPA observed all staff to be wearing masks. However, residents were observed not consistently wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as 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. To date, the facility has not had a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.


The following recommendations were made:
-N95 fit testing for all staff

No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.
SUPERVISORS NAME:
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3