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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802295
Report Date: 05/26/2021
Date Signed: 05/26/2021 01:46:59 PM

Document Has Been Signed on 05/26/2021 01:46 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:RESIDENCE IV, THEFACILITY NUMBER:
405802295
ADMINISTRATOR:MARCOS, MEYNARDFACILITY TYPE:
740
ADDRESS:347 CALLE LUPITATELEPHONE:
(805) 549-0328
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 6CENSUS: 5DATE:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Meynard Marcos, Licensee/AdministratorTIME COMPLETED:
02:00 PM
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 At 12:03 pm, on 05/26/2021, Licensing Program Analysts (LPAs) Darlene Chavez and Arien Diaz conducted an unannounced annual infection control inspection of the facility above. LPAs were greeted by staff and stated the reason for their visit. Administrator Meynard Marcos arrived at the facility at approximately 12:30 pm. LPAs toured the facility. LPAs' initial tour of the facility resulted in observations which were immediately addressed by the administrator and facility staff: At 12:06 pm, water stains on entrance ceiling were observed. Administrator is working on repairing these. At 12:07 pm, garage door was locked to secure chemicals in cabinets in garage. At 12:19 pm, delayed egress alarms in bedrooms (3) were made active. At 12:54 pm, pet droppings were cleared in backyard. At 12:55 pm, the screen door to the backyard was repaired. At 12:56 pm, mold stains outside house near Northeast bedrooms was cleaned.

At 12:58 pm, LPA Chavez conducted Infection Control mitigation module with administrator. Administrator was instructed to immediately search for an N95 fit testing vendor. No other corrections found in mitigation module..

Exit interview conducted and report printed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Arien Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2021
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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