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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601675
Report Date: 10/31/2024
Date Signed: 11/01/2024 07:56:17 AM

Document Has Been Signed on 11/01/2024 07:56 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/
DIRECTOR:		LEAH AVILAFACILITY TYPE:
740
ADDRESS:725 SANTA BARBARA ST.TELEPHONE:
(626) 796-6600
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
10/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:14 PM
MET WITH:Grace Luis - StaffTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Grace Luis an explained the reason for the visit.

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, laundry room, a detached garaged, a backyard area, a front porch/yard.

LPA conducted a tour of the facility with Grace Luis and observed the following:
Facility is in good repair indoor and outdoor. Living room/dining is in good repair. Kitchen was observed clean and stores sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Cleaning supplies, sharps, and medication were observed locked in the kitchen. Laundry area was observed in good repair. Three (3) bedrooms were observed in good repair with the required furniture, bedding supplies, and sufficient lighting. Two bathrooms were observed in good repair, water temperature was tested between 113.7-114.1 degrees F. Backyard and passageways were observed clear of obstructions and debris. Front porch provides a cover seating area. Carbon monoxide/Smoke detectors were tested and in good repair. No large bodies of water were observed. Fire extinguishers were observed. Facility has a first aid kit.

LPA reviewed files, medication, and P&I money for 5 residents and 5 staff. Records for 20 hours of training for 4 staff were not observed. Last fire drill was conducted on 11/7/23.

Administrator certificate was observed for Leah Avila #6020555740 exp. date: 10/9/24. Documents to renew have been submitted to the department. Emergency disaster plan and Infection control plan were reviewed.

Deficiencies were noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Leah Avila and copies of this report, LIC 809D, and appeal rights were provided.
Tony VasalloTELEPHONE: (818) 419-8131
Mary G FloresTELEPHONE: (323) 981-3965
DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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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Document Has Been Signed on 11/01/2024 07:56 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: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 4 out of 5 staff need to complete 20 hours of training for the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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Administrator will provide 20 hours of training to the staff and submit copies of the training to the department by POC due date 11/12/24.
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
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Based on record review, the licensee did not comply with the section cited above in last fire drill was conducted on 11/7/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Administrator will conduct an emergency drill and will provide a copy to the department by POC due date 11/7/24.
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: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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