425800827-4-11-2023-29-AS-JOLN-CQT28Q-20230411171042

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800827
Report Date: 04/11/2023
Date Signed: 04/11/2023 05:10:54 PM

Document Has Been Signed on 04/11/2023 05:10 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:	TINA'S GENTLE CARE HOMES II		FACILITY NUMBER:	425800827
ADMINISTRATOR:	VALENTINA ROBERTS		FACILITY TYPE:	740
ADDRESS:	1411 W. SABRINA COURT		TELEPHONE:	(805) 925-0748
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY: 6		CENSUS: 4	DATE:	04/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Michael Joseph Elizarde, Administrator and Valentina Roberts, Licensee		TIME COMPLETED:	05:20 PM

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Licensing Program Analyst (LPA) Jenny Olson arrived unannounced to conduct a one year required annual. LPA met with Licensee Valentina Roberts and Administrator Michael Joseph Elizarde and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The kitchen area was observed at 2:10 p.m. The facility has a sufficient supply of non-perishable and perishable food items. Cleaning supplies and disinfectants are stored under the sink and in the garage, inaccessible to clients. Knives are stored in a locked cabinet in the kitchen.

Common areas: Living and dining room furniture were observed to be in good condition. At 2:15 p.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced 02/07/2023.

The backyard had a table and umbrella. No bodies of water noted. The washer and dryer are in the garage. The garage is locked.

Restrooms: The three restrooms were clean and sanitary and in operating condition with non-skid mats. The bathrooms were sufficiently stocked with soap and paper towels. Around 2:25 p.m., the hot water temperature measured in the resident restrooms at 108.3 degrees Fahrenheit.

Bedrooms: There are four (4) resident rooms, which were furnished. Linen cabinets were located outside of the rooms, which stocked extra linens and towels.

Records: LPA reviewed resident and staff records at 12:35 p.m. Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All files were complete. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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: TINA'S GENTLE CARE HOMES II	FACILITY NUMBER: 425800827
	VISIT DATE: 04/11/2023

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The LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete.

The last disaster drill was conducted on 2/7/2023.

Medications: Medications review began around 4:10 p.m.; medications are centrally stored and locked in a cabinet in the kitchen/living room Medications are labeled and checked for expiration dates.

Infection Control: The facility has an infection control plan The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Exit interview conducted. A copy of the report was printed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

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