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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603582
Report Date: 12/01/2022
Date Signed: 12/01/2022 11:59:31 AM

Document Has Been Signed on 12/01/2022 11:59 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SANTA BARBARA GUEST HOMEFACILITY NUMBER:
198603582
ADMINISTRATOR:AVILA, LEAHFACILITY TYPE:
735
ADDRESS:735 SANTA BARBARATELEPHONE:
(626) 796-6600
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 6CENSUS: 5DATE:
12/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Leah Avila - Applicant TIME COMPLETED:
12:00 PM
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an announced pre-licensing visit at the facility.
LPA met with Leah Avila applicant and conducted a tour of the facility.

Fire inspection clearance was conducted on 10/29/22 and facility is cleared for a capacity of 6 ambulatory clients age range from 18-59 years old. The physical plant consist of a single family home, a kitchen, a dining room, a living room, (4) bedrooms; of which (3) are shared client bedrooms, and (1) staff room, (2) bathrooms, a laundry area, a garage, a porch with shaded sitting area, and a backyard area.

LPA Flores conducted a tour with Leah Avila applicant and observed the following:
Living/dining area
Sitting area available, furniture is in good condition.
Kitchen area
Kitchen is clean and in good repair. Medication cabinet, cleaning supplies cabinet under sink, and additional cabinet next to refrigerator and sharps drawer are kept locked. Dishes and utensils available. Sufficient food was observed for at least 2 days of perishables and 7 days of non-perishables.
Bedrooms
All bedrooms have the required bedding supplies, furniture, sufficient lighting and are in good repair.
Bathrooms
Bathroom #1 (B1) is a full bathroom with a shower and tub. Tub has about 4 patches that vary from the length of a finger to the size of the palm of an adult hand of paint peeling, and has a 3 inch grab bar on the outer side of the tub and a grab bar on the wall and a skid mat was observed. Water temperature was tested at 111.7 degrees F., which is within the required 105-120 degrees F.
Infection Control
Signs and posters were observed throughout. Screening station, logs for visitors, staff, and clients were observed. Hand sanitizer available.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA BARBARA GUEST HOME
FACILITY NUMBER: 198603582
VISIT DATE: 12/01/2022
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Staff/Resident Files
LPA reviewed files for 7 staff and 5 clients, all documents are current and available for review.
Medication
Medication was reviewed for 3 clients, medication is available and kept locked.

Smoke/Carbon Monoxide detectors were tested and in working condition. Fire Extinguishers were observed and last checked on December 24, 2021, and First Aid kit was reviewed and has all the required items.

LPA Flores conducted Component III with Leah Avila applicant.

Applicant will repair the following items within 7 days and submit pictures to the department:
  • Applicant will repair shower tub paint peeling.

Physical plant does not meet Title 22 Regulations at this time.

Exit interview was conducted with Leah Avila and a copy of this report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC809 (FAS) - (06/04)
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