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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800142
Report Date: 09/03/2024
Date Signed: 09/03/2024 02:12:09 PM

Document Has Been Signed on 09/03/2024 02:12 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CASA DE FLORESFACILITY NUMBER:
405800142
ADMINISTRATOR/
DIRECTOR:		JONATHAN D. ROBERTSFACILITY TYPE:
741
ADDRESS:1405 TERESA DRIVETELEPHONE:
(805) 772-7372
CITY:MORRO BAYSTATE: CAZIP CODE:
93442
CAPACITY: 120CENSUS: 77DATE:
09/03/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:48 AM
MET WITH:Jonathan Roberts, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Miller made a subsequent visit to facility on 9/3/24, to conduct the annual inspection that was initiated on 1/30/24. LPA met with Administrator and explained the purpose of the visit. LPA interviewed staff and obtained relevant documentation.

LPA conducted a cursory tour of the facility and visited 3 resident rooms and one vacant room. Rooms are well lit, clean and free of odor. LPA noted that the facility is clean and in good repair, exits are clear and free of all hazards. LPA previously conducted a medication audit and found that Centrally Stored Medication Record (CSMR) and Medication Administration Record (MAR) to be current and accurate. LPA did not find any violations, during the physical tour walk through.

LPA conducted 4 of 5 staff interviews, and zero resident interviews. The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2023 and 2024.



No citations or violations were issued on this annual inspection. Exit interview conducted, report read, and report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024
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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