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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801971
Report Date: 07/29/2022
Date Signed: 07/29/2022 04:12:19 PM

Document Has Been Signed on 07/29/2022 04:12 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:PASO ROBLES SENIOR LIVINGFACILITY NUMBER:
405801971
ADMINISTRATOR:ERIC BUNTEFACILITY TYPE:
740
ADDRESS:380 SCOTT STREETTELEPHONE:
(805) 227-4383
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6CENSUS: 5DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Eric Bunte/LicensceeTIME COMPLETED:
12:45 PM
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
 At 10:15am on 07/29/2022, Licensing Program Analyst (LPA) Jeffries arrive at the front door announced the reason for the visit. LPA was screened for COVID-19 protocols at the time of entrance. LPA met the Licensee Eric Bunte and announced the reason for the visit.

Licensee and LPA conducted a walking tour of the facility. The facility is a 4 bedroom, 3 bathroom with kitchen, living room and dining room and small living room adjacent to the dining room. Two bedrooms have double occupancy and share one and a half resident bathrooms. One room is a single privet room and licensee only cares for five residents at a time. per licensee. Bathrooms are stocked with liquid soap and paper towels; all three bedrooms have hand sanitizer. The fourth bedroom and third bathroom are staff live-in quarters and are located on the second floor of the facility. LPA observed the medication closet in the hallway past the kitchen and dining room area and staff and resident files are also kept in the same closet. LPA observed all required postings and signs including Provider Information Notices (PINs) on a clipboard in centralized hallway of the facility. LPA observed more than a two day supply of non perishable foods and more than a seven day supply of perishable foods. LPA checked fire detectors and carbon monoxide detectors all in good working condition. LPA observed and ample amount of PPE supplies. LPA did not discover any visible deficiencies or citations at this time during the facility tour.

LPA and Licensee conducted the Annual Infection control model portion of the inspection. There were no deficiencies or citations discovered at this time during the annual Infection Control inspection.

Exit interview, report signed, and report emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2022
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