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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421702848
Report Date: 04/26/2022
Date Signed: 04/26/2022 05:34:48 PM

Document Has Been Signed on 04/26/2022 05:34 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:COVENANT LIVING AT THE SAMARKANDFACILITY NUMBER:
421702848
ADMINISTRATOR:LAURIE SMALLFACILITY TYPE:
741
ADDRESS:2550 TREASURE DRIVETELEPHONE:
(805) 687-0701
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY: 379CENSUS: 349DATE:
04/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jennifer Leggett, Associaet Executive DirectorTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced visit to the facility. While conducting an Annual Infection Control Inspection, LPA Kontilis noted the following deficiencies:
At approximately 3:15 pm on 4/25/2022, LPA conducted a record review that confirmed the following:
<A criminal background fingerprint clearance had not been conducted for Staff 1 (S1), Staff 2 (S2) and Staff 5 (S5). S1 has been working in the facility since 12/21/2021. S2 has been working in the facility since 9/19/2019. Staff 5 (S5) has been working in the facility since 12/2/2019. Karen Harris, Director of Human Resources confirmed S1, S2, and S5 were not given a criminal background fingerprint clearance.
<Staff 6 (S6) was disassociated on or about 2/23/2015. S6 has been employed at the facility since 12/9/2014. A criminal background fingerprint clearance for S6 is required due to the time lapse in the association.
<Staff 3 (S3) who has been employed at the facility since on or about 1/8/2018 was disassociated from the facility on 11/7/2018. Staff 4 (S4) was disassociated from the facility on 11/18/2018. Karen Harris, Director of Human Resources stated S3 and S4 continue to work in the facility.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):
Civil penalties issued. Exit interview conducted. Today’s report, Civil Penalty, and Appeals Rights were reviewed and emailed to Jennifer Leggett, Associate Executive Director
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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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Document Has Been Signed on 04/26/2022 05:34 PM - It Cannot Be Edited


Created By: Kristin Kontilis On 04/26/2022 at 03:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COVENANT LIVING AT THE SAMARKAND
FACILITY NUMBER: 421702848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2022
Section Cited
CCR
87355(e)(1)

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87355(e)(1) Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department…
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Associate Executive Director (ED) agrees to obtain criminal background fingerprint clearance for S1, S2, and S5. ED stated S1, S2, and S5 will not work until criminal background clearance has cleared.

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This requirement is not met as evidenced by:
Based on observation and record review, the licensee did not comply with the section cited above as a criminal background fingerprint clearance was not conducted for S1, S2, and S5, which poses an immediate health and safety risk to persons in care.
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Type A
04/27/2022
Section Cited
CCR87355(e)(2)

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87355(e)(2) Criminal Record Clearance: (e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c) or...
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Associate Executive Director (ED) agrees to obtain criminal transfer for S3 and S4. ED will submit copies of criminal background clearance transfer request, LIC508 and photo identifications to CCL by 4/27/2022. ED stated that they will not employ staff unless they are associated with the facility.
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This requirement is not met as evidenced by:
Based on interviews, the licensee did not comply with the section cited above as the licensee did not ensure that S3 and S4 were associated, which poses an immediate safety risk to persons in care.
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Human Resources Assistant submitted documents for S3 and S4 to CCL to be associated to the facility. POC Cleared this date.
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:Kelly Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022


LIC809 (FAS) - (06/04)
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