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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850527
Report Date: 12/13/2024
Date Signed: 12/13/2024 01:36:13 PM

Document Has Been Signed on 12/13/2024 01:36 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:WELCOME HOME ATASCADEROFACILITY NUMBER:
405850527
ADMINISTRATOR/
DIRECTOR:
FLORES, RACQUEL PFACILITY TYPE:
740
ADDRESS:14900 EL CAMINO REALTELEPHONE:
(805) 703-4686
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 60CENSUS: 0DATE:
12/13/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Steve Chou & Raquel FloresTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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At 11:00am on 12/13/2024, Licensing Program Analyst (LPA) De Leon conducted the Pre-Licensing visit. LPA met with Administrator, Raquel P. Flores and announced the purpose of the visit.

This facility is a large 60 capacity 1 floor building, 3 wings North, South and West with a total of 30 resident rooms, 6 resident showers, 19 resident bathroom with toilets, 2 common area restrooms and 3 staff restroom. The fire clearance is approved for a maximum capacity of 60 residents with 10 that may be bedridden in any bedroom. The facility has two large driveway gates that remain unlocked during business hours. The facility has 2 courtyards with fencing all the way around and gates. The entrance of the facility has front receptionist office/desk, lounge area and restrooms. The North Wing has resident rooms, bathrooms, showers, supply closets, dining room/activity room, Activity office, and one other staff office, medication room with locked key coded door, LPA inspected random rooms 21, 23, 24, 25, 26, 28 and 30, all rooms have closets and exterior door exiting door alarms. The South Wing has residents rooms, bathrooms, and showers along with key coded locked storage closets, Staff break rooms and restrooms with lockers, LPA inspected rooms 1, 2, and 13 all rooms met requirements. The West Wing has Commercial Kitchen, cleaning closet, emergency supply of food and water, walk in refrigerator is set at 36.5 degrees and freezer is set at 0 degrees, resident rooms, bathrooms, showers, laundry room with storage for clean linens kept separately then soiled or dirty items and a staff restroom.

The facility has video surveillance system and sketches marked with location of all cameras. The facility has emergency exiting lights, exiting door alarms, fire extinguishers charged and tagged 03/14/2024. The facility is set up to accommodate dementia residents, with locked storage rooms, locked medication room, locked cleaning closets, exiting alarms and a fenced courtyards. All cleaning, laundry products and anything that can pose a danger will be locked and inaccessible to residents in care. All rooms and bathrooms have operable pull cords for resident use. All restrooms have secured grab bars present. Facility is clean, safe and sanitary. Fire clearance and sketches match the facility as it is today.
CONTINUED on LIC809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: WELCOME HOME ATASCADERO
FACILITY NUMBER: 405850527
VISIT DATE: 12/13/2024
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LPA reviewed facility emergency evacuation plan and infection control which met regulation requirements.

Administrator and LPA conducted a full review of the pre-licensing care tools and LPA conducted Component III with Licensee/Administrator on visit.

"Pre-Licensing is complete and this facility has no deficiencies."


Exit interview and copy of report provided to Licensee/Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
LIC809 (FAS) - (06/04)
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