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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802280
Report Date: 06/23/2021
Date Signed: 06/23/2021 04:02:01 PM

Document Has Been Signed on 06/23/2021 04:02 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:C.A.L.L. - VALDEZ HOUSEFACILITY NUMBER:
405802280
ADMINISTRATOR:CHRIS QUATTLEBAUMFACILITY TYPE:
740
ADDRESS:4305 VALDEZ AVETELEPHONE:
(805) 460-6663
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 4CENSUS: 4DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Kylan Reynoso, House SupervisorTIME COMPLETED:
11:20 AM
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On 6/23/21, at 9:15 AM, Licensing Program Analyst (LPA) Toan Luong conducted an unannounced onsite one year infectious control annual visit to the facility. LPA met with House Supervisor (HS) Kylan Reynoso. LPA explained the purpose of the visit.

HS took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department.

The facility is a Residential Care Facility for the Elderly. During the facility tour, LPA advised HS that CDSS PINs with recent information should be posted and accessible to visitors and residents. LPA recommended hand sanitizing should be available at entry point. LPA discussed benefits of fit-testing N95 masks for staff to avoid temporary staffing of nurses and other trained professionals.

LPA reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with HS to satisfaction.

Exit interview was conducted. No deficiencies were cited. Report was emailed to HS.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
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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