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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601675
Report Date: 11/07/2023
Date Signed: 11/07/2023 11:38:13 AM


Document Has Been Signed on 11/07/2023 11:38 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:SANTA BARBARA GUEST HOME #2FACILITY NUMBER:
198601675
ADMINISTRATOR:LEAH AVILAFACILITY TYPE:
740
ADDRESS:725 SANTA BARBARA ST.TELEPHONE:
(626) 796-6600
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY:6CENSUS: 6DATE:
11/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Leah Avila - Administrator TIME COMPLETED:
11:50 AM
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
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual investigation visit using the CARE inspection tool. LPA met with Jennifer Miano Caregiver and explained the reason for the visit. Leah Avila arrived within 10 minutes.

The Facility is licensed to serve 6 ambulatory adults over the age of 60 years. The Facility is a single home in residential area with 3 shared rooms, 1 staff room, 2 bathrooms, a kitchen, living room, dining room a detached garaged, a backyard area, a front porch, and a front yard.

LPA conducted a tour with Jennifer Miano and observed the following:
Facility is in good repair indoors and outdoors. All passages, driveway, and exit are free of obstructions. Living/dining room has sufficient lighting and seating. Kitchen stores sufficient food supplies for at 7 days of non-perishable and 2 days of perishables. Sharps and cleaning supplies were observed locked in cabinet/ drawer. Each room (3) has sufficient lighting, furniture, and bedding supplies. Bathroom's (2) are in working condition, with grab bars/skid mat. Water temperature was tested in bathroom #1 at 132.6 and bathroom #2 at 134.4 degrees F., which is not within the required 105-120 degrees F. Smoke/Carbon Monoxide detectors were tested and in working condition. Fire extinguishers were observed and last check on 7/5/23. Front porch has some seating area for residents. Backyard was observed clean. LPA reviewed Emergency Disaster Plan, Infection Control, Liability Insurance and Surety Bond(facility handles P&I). Last emergency drill was conducted on 2/9/23.
LPA Flores reviewed medication, files, and P&I for 5 residents. LPA reviewed 5 staff files. Administrator certificate was reviewed for Leah Avila #6020555740 exp. date: 10/9/24. Staff #4(S4) last first aid/CPR training was on 8/1/21.

Deficiencies were noted during this visit per Title 22 Regulations.

Exit interview was conducted with Leah Avila and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
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 4


Document Has Been Signed on 11/07/2023 11:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: SANTA BARBARA GUEST HOME #2
FACILITY NUMBER: 198601675

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in water temperature tested in Bathroom #1 tested at 132.6 and in bathroom #2 tested at 134.4 which is not within the required 105-120 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2023
Plan of Correction
1
2
3
4
Administrator adjusted water heater during the visit and will certify that will ensure water temperature is within the required 105-120 degrees F., at all times by POC due date 11/8/23.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 11/07/2023 11:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: SANTA BARBARA GUEST HOME #2
FACILITY NUMBER: 198601675

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in last emergency drill conducted was on 2/9/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2023
Plan of Correction
1
2
3
4
Administrator will conduct an emergency drill and will submit a copy of report to the department by POC due date 11/14/23.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4