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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800854
Report Date: 11/09/2022
Date Signed: 11/10/2022 04:37:20 AM

Document Has Been Signed on 11/10/2022 04:37 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:FULL CIRCLE RESIDENCE IIFACILITY NUMBER:
405800854
ADMINISTRATOR:MANUEL, ROSITAFACILITY TYPE:
740
ADDRESS:483 NOEL ST.TELEPHONE:
(805) 489-9658
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY: 6CENSUS: 6DATE:
11/09/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rod Peralta / Care GiverTIME COMPLETED:
03:39 PM
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At 1:45pm on 11/09/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct a resident transfer check. Resident was recently transferred from a different facility and in the best interest of the resident a transfer wiliness check was conducted.

LPA met with caregiver Rod Peralta (S1) and indicated that Resident 1 (R1) was doing fine and settled. R1 was currently sleeping. Care giver stated that R1 is doing well. Care giver stated that R1 arrived at the facility with rash in groin and rear end area and are slowly observably getting better. R1 currently has home health through Central Coast home Health services daily. Care Giver stated R1 has family visitor daily.

LPA observed the facility to be clean and in good repair no issues with R1 transfer.

Exit interview, report signed, and report emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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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