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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801960
Report Date: 10/15/2022
Date Signed: 10/15/2022 04:13:14 PM

Document Has Been Signed on 10/15/2022 04:13 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:BOB & CORKY'S CARE HOME IIIFACILITY NUMBER:
405801960
ADMINISTRATOR:DEBORAH COLEFACILITY TYPE:
740
ADDRESS:2456 SANTA CLARATELEPHONE:
(805) 400-0506
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 6CENSUS: 5DATE:
10/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Joel Wobrock, Licensee/AdministratorTIME COMPLETED:
04:26 PM
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On 10/15/22 at 3:40 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Joel Wobrock, Licensee/Administrator, and explained the purpose of the visit.

LPA toured the facility with the licensee and observed the following: The facility has infection control signage at the front door and signage throughout the facility on handwashing and use of masks. Licensee will post cough etiquette signage, take photo and send to LPA by end of day 10/17/22. Upon entry to the facility, LPA was screened. Staff are wearing masks. The facility has soap and paper towels in resident bathrooms (3). A fire extinguisher is located in the kitchen. The extinguisher is fully charged and was inspected on 4/11/22. The facility’s northeast gate has an open section at the end (left side) which could be a safety hazard to residents with memory care issues, if they were to try to exit in that space. Licensee will close-up the space, take a photo and send to LPA by 10/22/22. The facility has a storage shed which needs a lock as there are paints stored there. The gate leading to the shed is not an exit gate, however, it is possible for residents to access. Licensee will place a lock on the shed, take a photo and send to LPA by 10/22/22. On the front patio area, there is a board protruding which could be a trip hazard. Licensee will enforce the board so that it is flush with other boards, take a photo and send to LPA by 10/22/22.

At 3:55 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: 10/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2022
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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