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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336406703
Report Date: 03/03/2023
Date Signed: 03/03/2023 12:32:52 PM

Document Has Been Signed on 03/03/2023 12:32 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CASA SANTALLAFACILITY NUMBER:
336406703
ADMINISTRATOR:PETER O. SANTALLAFACILITY TYPE:
735
ADDRESS:12026 DRESSAGETELEPHONE:
(951) 351-4284
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 5CENSUS: 2DATE:
03/03/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Peter O. Santalla, AdministratorTIME COMPLETED:
12:35 PM
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Licensing Program Analysts (LPAs) Yolanda Delgado and Kathleen Banrasavong made an unannounced visit to the facility to conduct a Case Management visit due to a report of a death. LPAs Yolanda Delgado and Kathleen Banrasavong met with Administrator Peter Santalla, discussed the procedures in reporting Deaths to CCLD, observed two (2) clients in care and two (2) staff present at the facility, sufficient food supply and working utilities. No health and safety concerns at this time; a request was made to provide the following documents:

- IPP (received)
- Placement Agreement (received)
- Physician's Report (received)
- List of Medications (received)
- Proof of submission of SIRs (received)
- Care Plan (received)
- Hospitalization documents (requested)

An exit interview was conducted, this report was discussed with the facility Administrator Peter Santalla and a copy of this report was provided during this visit.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2023
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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