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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801512
Report Date: 10/13/2022
Date Signed: 10/13/2022 02:51:45 PM

Document Has Been Signed on 10/13/2022 02:51 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:WELCOME HOME RESIDENTIAL CARE FOR THE ELDERLYFACILITY NUMBER:
405801512
ADMINISTRATOR:EVELYN I. FLORENTINOFACILITY TYPE:
740
ADDRESS:402 WOODBRIDGE ST.TELEPHONE:
(805) 784-0540
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 6CENSUS: 5DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Evelyn Florentino, Licensee/AdministratorTIME COMPLETED:
03:08 PM
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On 10/13/22 at 1:31 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with the caregiver, and explained the purpose of the visit. At 1:56 pm, Evelyn Florentino, Licensee/Administrator arrived at the facility, and LPA explained the purpose of the visit.

LPA toured the facility with the caregiver until the licensee arrived upon which LPA and licensee toured the facility. LPA observed the following: The facility has infection control signage at the front door and handwashing signage in resident bathrooms and the kitchen. The facility is missing signage throughout the facility on cough etiquette and use of masks. Licensee will post these in the facility, take photos, and send to LPA by 10/14/22. Upon entry to the facility, LPA was screened and asked to sign-in. Staff are wearing masks. The facility has soap and paper towels in resident bathrooms (2). Fire extinguisher is located in the hall across from the kitchen. The extinguisher is fully charged and was inspected on 2/09/22. The sliding glass door in the dining room to the backyard was difficult to slide open/closed. Licensee will fix the door and send a video of the movement to LPA by 10/20/22. The northwest facing exterior gate self-closed but did not latch properly. Licensee will fix and send a video to LPA by 10/20/22.

At 2:15 pm, LPA conducted the Infection Control mitigation module with the licensee. No deficiencies cited.

Exit interview conducted and report emailed to the licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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