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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800987
Report Date: 11/03/2021
Date Signed: 11/03/2021 06:14:02 PM

Document Has Been Signed on 11/03/2021 06:14 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:IRENE'S BOARD & CAREFACILITY NUMBER:
405800987
ADMINISTRATOR:ANGELITA O. MARAVILLASFACILITY TYPE:
740
ADDRESS:220 VIA PROMESATELEPHONE:
(805) 227-0276
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6CENSUS: 4DATE:
11/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:14 PM
MET WITH:Angelita Maravillas, Licensee/AdministratorTIME COMPLETED:
03:22 PM
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At 2:14 pm, on 11/03/2021, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced annual infection control inspection of the facility above. LPA informed Licensee/Administrator Angelita Maravillas of the reason for the visit. LPA and Ms. Maravillas toured the facility.

LPA’s initial tour of the facility resulted in observations which were immediately addressed by facility: At 2:14 pm, LPA requested the facility screen LPA for COVID-19 upon entry to facility which was immediately conducted. The facility has two front doors, one of which was locked, however, licensee will add signage to the sliding glass door to direct visitors to the main front entrance which is the central entry point. At 2:15 pm, LPA entered the facility and observed the licensee and six guests/family in the front room not wearing masks. Licensee stated they were gathering for a family occasion and didn’t have masks on because they were just about to eat. LPA observed food on the table and kitchen areas. At 2:21 pm, LPA noticed the bathroom at the back of the house did not have handwashing signage. License will post immediately. At 2:29 pm, LPA tested the delayed egress in the bedroom at the front of the house, and it did not alarm. Licensee immediately reset it, tested it, and it worked. At 2:32 pm, LPA observed that the complaint poster was missing from the facility. Licensee will post a 20"x26" poster in yellow immediately. Licensee will begin recording daily temperature checks and symptom screening of residents, staff, and visitors effective today.

At 2:39 pm, LPA conducted the Infection Control mitigation module with Ms. Maravillas. No deficiencies noted. However, licensee will send LPA training sheet for staff who have been fit tested for N95 respirators and will send to LPA by 11/05/21.

Exit interview conducted and report emailed to the licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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