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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800705
Report Date: 08/18/2020
Date Signed: 08/18/2020 05:13:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117
FACILITY NAME:LOS OSOS RESIDENTIAL CAREFACILITY NUMBER:
405800705
ADMINISTRATOR:AMILIORANTE UBAYFACILITY TYPE:
740
ADDRESS:1667 18TH ST.TELEPHONE:
(805) 528-5672
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY:6CENSUS: 0DATE:
08/18/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:18 PM
MET WITH:Marilou Ubay, LicenseeTIME COMPLETED:
04:32 PM
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On 8/18/2020, Licensing Program Analyst (LPA) Darlene Chavez conducted a Case Management (Facility Closure) visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted via video chat. The purpose of the visit is to document the closure of this facility which was initiated by the Administrator/Licensee Marilou Ubay in a Certification of Non-operation dated 08/11/2020 to CCL Re: Closure of Los Osos Residential Care RCFE. The LPA met with the Licensee Marilou Ubay.

Licensee stated she relocated the 4 residents to her other facility, Los Osos Residential II, on July 8, 2020. Licensee decided not to accept any new residents at facility above and close facility. Facility closed on 08/11/2020. Licensee has consolidated facilities and has listed this residence for sale.

Upon arrival at 4:18 pm LPA observed a For Sale sign in front of the property. The Licensee’s car was the only car in the driveway. License led LPA into the garage. LPA observed a dining room set, credenza, artificial tree, and recliner. The licensee stated these items had been moved from the house into the garage to be sold or given away. At 4:23 pm LPA observed an empty refrigerator in the kitchen and empty kitchen cabinets. LPA observed the dining room and living room had no furniture whatsoever. LPA toured bedrooms 1, 2, and 3. All bedrooms and closets were empty. The hallway was void of contents. LPA observed zero linens, cleaning supplies, or sanitary products in bathrooms 1 and 2. LPA toured the outside of the property which showed no signs of inhabitants.

As of today, it does not appear the facility is operating. LPA will make contact with Licensee for return of the License for the facility. Per observation today LPA will be submitting the file for closure to the LPM.

At 4:32 pm, a telephonic exit interview was conducted with Marilou Ubay, and an electronic copy of the report was emailed for signature to be returned to LPA Chavez by email.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) -59-343
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: 805-450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2020
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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