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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801856
Report Date: 07/26/2022
Date Signed: 07/27/2022 05:37:07 AM

Document Has Been Signed on 07/27/2022 05:37 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:A HEAVENLY HOME, LLCFACILITY NUMBER:
405801856
ADMINISTRATOR:JENNIFER R. JIMENEZFACILITY TYPE:
740
ADDRESS:1920 PROSPECT AVENUETELEPHONE:
(805) 296-3239
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6CENSUS: 6DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Clementina Garcia/AdminstratorTIME COMPLETED:
01:45 PM
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 At 10:40am on 07/26/2022, Licensing Program Analyst (LPA) Jeffries arrived at that facility to conduct and unannounced annual infection control inspection. LPA was met at the front door by staff and asked to screen for COVID-19 protocols. LPA met with Administrator Clementina Garcia and announced the reason for the visit.
Administrator and LPA conducted a physical tour of the facility. The facility is a 4 bedroom, 2 bathroom, kitchen, living room and laundry room set up, medication cart is locked in the laundry room. LPA observed working fire/carbon-monoxide detectors in each room in working order. LPA observed at least two days of non perishable and seven days of perishable foods at this facility. LPA noted that there are 4 additional sister facilities on the same campus and all meals are prepared at facility 405802304 and brought to each of the five facilities for each meal. All staff have a single entry point at facility 405802302 and each facility has a single entry point of all residence and visitors at the front door. LPA observed an ample supply of PPE located in the garage of the facility and additional PPE is located on the campus in the other facilities.
Administrator and LPA conducted the infection control module of the annual inspection tool. LPA did not find any violations or deficiencies during the infection control module. At this time there are no violations or deficiencies cited.

Exit interview, report singed, and repot emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
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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