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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703748
Report Date: 02/10/2020
Date Signed: 11/14/2022 10:52:45 AM

Document Has Been Signed on 11/14/2022 10:52 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, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117
FACILITY NAME:PURISIMA HILLSFACILITY NUMBER:
421703748
ADMINISTRATOR:SUSAN MARSHFACILITY TYPE:
740
ADDRESS:237 ALDEBARAN AVENUETELEPHONE:
(805) 733-4395
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 6CENSUS: 3DATE:
02/10/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Susan Marsh/LicenseeTIME COMPLETED:
03:30 PM
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At 12:00pm on 02/10/2020, Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility to conduct an unannounced annual inspection. LPA met with Licensee Susan Marsh. This facilities last inspection was conducted on 02/08/2019.
LPA toured facility with Licensee. The facility is maintained in conformance with state fire marshal regulations. Smoke detectors and carbon monoxide detectors functioning throughout the facility. Fire extinguisher is fully charged. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 70 degrees F. Hot water temperature tested and read at 119.6 degrees F at 2:45PM. Residents’ rooms are appropriately furnished with adequate lighting. LPA observed more than two days of perishable and more than seven days of non-perishable food. A written disaster and mass casualty plan is readily available located on the facility kitchen wall.
LPA reviewed client and staff files. All client files reviewed have current physicians report including TB screening, current needs and services plans and admission agreements. Staff files reviewed had current first aid certificates, health screenings including TB screening and adequate training hours.

LPA reviewed medications. Medications are stored in a locked cabinet in the dining room. There is a signed and dated order from a physician for prescription and PRN medication. LPA observed the medication administration record (MAR) and medications are given per physician's orders. Technical assistance on screens that need repair.

Exit interview, Technical Assistance addressed, report given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2020
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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