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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421700369
Report Date: 05/25/2022
Date Signed: 05/25/2022 10:31:15 AM

Document Has Been Signed on 05/25/2022 10:31 AM - 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:ATTERDAG VILLAGE OF SOLVANGFACILITY NUMBER:
421700369
ADMINISTRATOR:CHRIS PARKERFACILITY TYPE:
741
ADDRESS:636 N ATTERDAG ROADTELEPHONE:
(805) 688-3263
CITY:SOLVANGSTATE: CAZIP CODE:
93463
CAPACITY: 188CENSUS: 142DATE:
05/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:02 AM
MET WITH:Chris Parker/AdministratorTIME COMPLETED:
11:18 AM
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 At 8:15am on 05/25/2022, Licensing Program Analyst (LAPA) Mark Jeffries arrived at the facility to conduct the annual infection control inspection. LPA met with Administrator Chris Parker and announced who he was and reason for the visit.
LPA and Administrator conducted the infection control module with no deficiencies found. Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department.
The facility is a Continuing Care Retirement Community that has a campus consisting of 26 buildings. Buildings 1-14 are designated for Independent Living. Building 15 is designated for Assisted Living and Memory Care. Building 16 is a skilled nursing facility. Building 17 is the Maintenance Shop. Building 18 is the Administration Building. Building 19 is the generator area. Building 20 is designated for Assisted Living on the second floor, and the first floor is the pool and other amenities. Buildings 21-25 are Independent Living. Building 26 is a utilities building. Building 15 is Memory Care, delayed regress, is functioning properly. Facility uses program Point Click Care for Medication Administration Records. Facility has activities calendars for Memory Care and Assisted Living. In building 15. LPA observed required postings including Provider Information Notices and ample supply of PPE supplies located throughout the facility. LPA did not observe any regulation related risks to residents in care during walk through of the facility at this time.

No deficiencies cited, exit interview, report singed and copy provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2022
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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