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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850223
Report Date: 03/19/2025
Date Signed: 03/19/2025 02:47:57 PM

Document Has Been Signed on 03/19/2025 02:47 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BOB & CORKY'S CARE HOME VIFACILITY NUMBER:
405850223
ADMINISTRATOR/
DIRECTOR:
SHAWNA HARNEYFACILITY TYPE:
740
ADDRESS:3198 ROSE AVE.TELEPHONE:
(805) 400-0506
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 6CENSUS: 6DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Administrator - Shawna HarneyTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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At 8:35am on 03/19/2025, Licensing Program Analyst (LPA) Haner-Tomasko, arrived unannounced at the facility to conduct the annual facility inspection. LPA met with Administrator Shawna Harney, announced who he was, and the reason for the visit.
Administrator and LPA conducted a full tour of the facility. The facility is a 5-bedroom 4-bathroom house, with a living room, kitchen, and dining area. There is one dual occupancy bedroom. Three of the bedrooms have on-suite bathrooms and there is one public full restroom. All bathrooms have walk-in showers. The garage is locked and this is where the chemicals, laundry, and medications are kept. There is a patio located at the front of the facility and a fenced backyard, both with chairs and umbrellas for residents and visitors to safely enjoy shaded outdoor space. LPA noted that the bathrooms are clean. Hand soap and paper towels available in each one. LPA observed a full first aid kit available. LPA noted fire extinguisher in the kitchen serviced on 4/4/2024. LPA noted smoke alarms/carbon monoxide detectors located in each room throughout the facility; all of these devices were tested and are functioning. LPA observed at least two days of perishable foods and more than seven days of non-perishable foods on hand at this facility. At 09:00am facility lost power due to a local PG&E power outage. Staff remained attentive to residents, regularly checking on them. Call system continued to function on battery backup. Gas stove was functioning to prepare food. LPA noted prior to outage the facility telephone was operational, all staff have mobile phones as backup. Facility located rental generator if outage becomes extended. LPA noted that all doors and exits were free of obstructions.

LPA reviewed centrally stored medications, staff files and resident files. Infection control and emergency/disaster plans reviewed. LPA and administrator conducted review of care modules.

Exit interview, report signed, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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