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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801856
Report Date: 08/22/2024
Date Signed: 08/22/2024 12:49:33 PM

Document Has Been Signed on 08/22/2024 12:49 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:A HEAVENLY HOME, LLCFACILITY NUMBER:
405801856
ADMINISTRATOR/
DIRECTOR:
JENNIFER R. JIMENEZFACILITY TYPE:
740
ADDRESS:1920 PROSPECT AVENUETELEPHONE:
(805) 296-3239
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6CENSUS: 6DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administratrator Clementina GarciaTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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At 9:30am on 08/22/2024, Licensing Program Analyst (LPA) Mark Jeffries arrived unannounced to the facility to conduct the annual inspection. LPA met with Administrators Karla Sanchez and Clementina Garcia. LPA announced who he was and the reason for the visit.

Administrator, staff and LPA conducted a physical tour of the facility. This facility is 4 bedroom and 2 shared bathroom facility. There is a locked room which contains a medication cart that is locked, a small refrigerator that has a pad lock and the facilities first aide kit. LPA observed resident bedroom to all have appropriate linin, lighting and storage. LPA observed there to be at least 2 days of perishable foods and at least 7 days of non perishable foods on hand. LPA noted that all meals are stored cooked and prepared at adjacent facility on the campus property approximately 40 yards away. LPA observed all required postings and emergency disaster plan. LPA observed combination smoke detectors and carbon monoxide detectors all hardwired throughout the facility. LPA observed a working fire extinguisher currently tagged and in the green pressure range. LPA noted that the facility is clean and in good repair, all exits are clear and free of all hazards. LPA conducted a medication audit and found that Centrally Stored Medication Record (CSMR) to be current and accurate. LPA did not find any other violations, technical or citations during the physical tour walk through.

Administrator, staff and LPA conducted the read through of all the annual inspection care tool modules. LPA noted that there were no other citations, violations, or technical issued during the control module. LPA conducted 2 of 2 staff interviews, and zero resident interviews. LPA conducted language survey. LPA noted that not citations, or violations were issued on this annual insepction.

Exit interview, report read, and report provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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