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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801838
Report Date: 02/18/2022
Date Signed: 02/18/2022 12:14:37 PM

Document Has Been Signed on 02/18/2022 12:14 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:A SPLENDID LIVING, RCFEFACILITY NUMBER:
425801838
ADMINISTRATOR:VALENTINA ROBERTSFACILITY TYPE:
740
ADDRESS:2305 CABALLERO LANETELEPHONE:
(805) 714-9063
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 6CENSUS: 4DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Valentina RobertsTIME COMPLETED:
12:20 PM
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On 02/18/22 at 10:40 a.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual visit to the facility. LPA met with Administrator Valentina Roberts and explained the purpose of the visit.

LPA was screened at the entrance, and LPA toured of the the residential care facility for the elderly. At 11:25 a.m., LPA discussed items in the Infection Control Module. All items in the Infection Control Module were answered yes. Infection Control Module was addressed with administrator to satisfaction.

No deficiency was issued. LPA conducted exit interview with administrator and emailed a copy of today's report and appeal rights to the administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2022
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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