<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850021
Report Date: 07/29/2021
Date Signed: 07/29/2021 03:03:27 PM

Document Has Been Signed on 07/29/2021 03:03 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:LORIE'S RCFE LLC #3FACILITY NUMBER:
425850021
ADMINISTRATOR:ROBLES, FREDAFACILITY TYPE:
740
ADDRESS:1017 E SUGAR BUSH DRTELEPHONE:
(805) 922-9525
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 6CENSUS: 2DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Claire AviadoTIME COMPLETED:
03:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 2:35 PM, Licensing Program Analyst (LPA) Toan Luong conducted an unannounced on-site one year infectious control annual visit to the facility after initiating facility risk assessment. LPA met with Administrator Claire Aviado and explained the purpose of the visit.

Administrator Claire Aviado 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 advise Administrator to post latest CDSS PINs to be accessible to residents, staff, and visitors. LPA discussed benefits of fit-testing N95 masks for staff to avoid temporary staffing of nurses and other trained professionals. LPA explained steps facility may take to fit-test staff.

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

Exit interview was conducted. No deficiencies were cited. Report was emailed to the Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1