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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800676
Report Date: 06/22/2021
Date Signed: 06/23/2021 06:57:38 AM

Document Has Been Signed on 06/23/2021 06:57 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:MYDOR'S OPEN GUEST HOME, INC. IIIFACILITY NUMBER:
425800676
ADMINISTRATOR:ANTENOR PORLUCASFACILITY TYPE:
740
ADDRESS:1018 N. NITA ST.TELEPHONE:
(805) 349-0334
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 6CENSUS: 6DATE:
06/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Antenor Porlucas, Administrator; Amelita Antonio, AdminstratorTIME COMPLETED:
11:40 AM
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On 6/22/21, at 9:05 AM, Licensing Program Analyst (LPA) Toan Luong initiated facility risk assessment questionnaire. LPA conducted an unannounced onsite one year infectious control annual visit to the facility. LPA met with Administrators Antenor Porlucas and Amelita Anotnio. LPA explained the purpose of the visit.

Administrators took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department.

The facility is a Residential Care Facility for the Elderly. During the facility tour, LPA advised Administrators that keys should be secured to staff or inaccessible to residents. LPA reminded administrators that masks should be worn at all times by staff until California Department of Public Health issues new orders. LPA discussed benefits of fit-testing N95 masks for staff to avoid temporary staffing of nurses and other trained professionals.

LPA reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with Administrators to satisfaction.

Exit interview was conducted. No deficiencies were cited. Report was emailed to Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2021
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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