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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603582
Report Date: 01/09/2024
Date Signed: 01/09/2024 03:32:51 PM

Document Has Been Signed on 01/09/2024 03:32 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
GREATER LA AC/SC, 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:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:56 AM
MET WITH:Aida Tabucal - Direct Support StaffTIME COMPLETED:
03:15 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
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA contacted Leah Avila Administrator over the phone and explained the reason for the visit. Staff Aida Tabucal arrived shortly after and assisted with the visit.

Facility is licensed to serve 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 toured the facility with staff and observed the following:
Home is in good repair indoor and outdoor. Living room and dining room have sufficient furniture. Kitchen is clean. Sharps, medication, and cleaning supplies were observed locked. Food supplies were observed sufficient for at least 2 days of perishables and 7 days of non-perishables. Laundry room was observed and emergency food supplies are store in cabinets above the washer/dryer. Each client room (3) has sufficient lighting, furniture, and bedding supplies. Each bathroom is in working condition with grab bars and skid mats, water temperature was tested between 105-106.5 degrees F. which is within the required 105-120 degrees F. Carbon Monoxide/Smoke detectors were tested and are in working condition. Fire extinguisher was observed and last checked on 6/5/23. Backyard is clean, shaded covered sitting area is available in the porch.
LPA reviewed medication, P&I, and files for 5 clients and 5 staff files. Infections control plan was last reviewed on 6/13/23. Emergency Disaster Plan was reviewed, no date of last reviewed. Last fire drill was conducted on 11/1/23.
No Deficiencies were noted during this visit. A technical assistance was recorded.
Exit interview was conducted with Aida Tabucal a copy of this report was email for signature due to technical issues during the visit.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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 2