<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801701
Report Date: 10/06/2022
Date Signed: 10/06/2022 11:30:05 AM

Document Has Been Signed on 10/06/2022 11:30 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:C.A.L.L.-CARMELITA HOUSEFACILITY NUMBER:
405801701
ADMINISTRATOR:BRENDA VICTORIAFACILITY TYPE:
740
ADDRESS:2660 FERROCARRILTELEPHONE:
(805) 466-8502
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 6CENSUS: 4DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Susan Samayoa, Lead CaregiverTIME COMPLETED:
11:35 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/06/22 at 10:15 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility listed above. LPA met with Staff #1 (S1) and explained the purpose of the visit. At 10:45 am, Susan Samayoa, Lead Caregiver, arrived at the facility, and LPA and explained the purpose of the visit.

LPA toured the facility with S1 and observed the following: The facility has soap and paper towels for residents’ bathrooms and handwashing signage. The fire extinguishers (two) are located in the hallway near resident bedrooms and the kitchen. The extinguishers are fully charged and were inspected on 11/08/21. The facility has infection control signage at the front door and signage throughout the facility on handwashing, cough etiquette and use of masks. Upon entry to the facility, LPA was screened. Staff were wearing masks. CDSS Provider Information Notices (PINs) were not readily accessible. Lead Caregiver will ensure these are made available in an accessible location for residents and staff. Lead Caregiver will send LPA a photo by 10/13/22.

At 10:55 am, LPA conducted the Infection Control mitigation module with the Lead Caregiver. No deficiencies cited.

Exit interview conducted and the report emailed to the Executive Director and Supervisor.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
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)
Page: 1 of 1