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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800467
Report Date: 10/06/2022
Date Signed: 11/14/2022 09:56:48 AM

Document Has Been Signed on 11/14/2022 09:56 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GARDEN CREEKFACILITY NUMBER:
405800467
ADMINISTRATOR:KIRK P KLOTTHORFACILITY TYPE:
740
ADDRESS:73 BROAD STREETTELEPHONE:
(805) 543-2311
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY: 72CENSUS: 52DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Kirt Klotthor/AdministratorTIME COMPLETED:
12:00 PM
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 At 8:36am on 10/06/2022, Licensing Program Analyst (LPA) Jeffries arrived unannounced at that facility to conduct and annual infection control inspection. LPA was screened for COVID-19 protocols at the front desk. LPA met with Administrator Kirt Klotthor and announced who he was and the reason for the visit.

At 9:05am, Administrator and LPA conducted a walking tour of the facility. The facility has three floors, two elevators and two stair cases. LPA observed mobile fire chairs in each stairwell. LPA observed more than 10 fire extinguishers and all were tagged with current dates and all in the green pressure zone, LPA observed recent fire inspection visit from Alpha Fire on fire irrigation system conducted on 09/19/2022. There are 65 rooms in the facility all with their own bathrooms and showers, LPA toured empty room and observed nonskid mats in showers and all appliances and sinks functioning correctly. LPA observed the Wellness center on the second floor where all medications are stored as well as PPE supplies. LPA observed PPE supplies in Administrators office and a third supply is located in the maintenance closet that supplies this and other facilities owned with this facility. LPA observed at least 2 days of nonperishable foods and at least 7 days of perishable foods in the facilities kitchen. LPA observed an over all clean facility with no visible hazards that would place residents in care in any harm during the cursory tour.

Administrator and LPA conducted the infection control portion of the annual inspection. There were no noted deficiencies and no citations issued during the infection control module of the annual inspection.

Exit interview, report signed, and report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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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