421703043-3-27-2025-29-AS-MJES-DF722G-20250327170040

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 421703043
Report Date: 03/25/2025
Date Signed: 03/27/2025 05:02:29 PM

Document Has Been Signed on 03/27/2025 05:02 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:	AVE'S BOARD AND CARE		FACILITY NUMBER:	421703043
ADMINISTRATOR/ DIRECTOR:	THELMA TABLADA		FACILITY TYPE:	740
ADDRESS:	111 CRESCENT AVE		TELEPHONE:	(805) 332-3139
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	03/25/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:02 AM
MET WITH:	Administrator, Thlema Tablada		TIME VISIT/ INSPECTION COMPLETED:	01:15 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	At 8:00am on 03/25/2025, Licensing Program Analysts (LPA's) Jeffries and Haner-Tomaso arrived unannounced to the facility to conduct the annual facility inspection. LPA's met with Administrator Thelma Tablada announced who they are and the reason for there visit. Administrator and LPA's conducted a physical tour of the facility. This is a 6 bedroom 5 bathroom home with a side and back yard with ample space for residents and visitors. Four of the bedrooms are single resident occupancy and one bedroom is double resident occupancy and one bedroom is a staff bedroom. There is a living room, dining room and kitchen with and annectent office and nook. LPA's noted that the medications are stored and locked in the cabinet in the office adjacent to the kitchen and the complete first aide kit is also located in this office area. Emergency water is located in the garage and there is a staff room with day bed and chairs for staff. LPA noted that the facility has at least 2 days of perishable food supply and at least 7 days of non perishable foods on hand for 6 residents and staff. LPA noted several fire extinguisher in the facility and garage that were all primed in the green reading. LPA's tested smoke detectors and carbon monoxide detectors to all be functional and working. LPA's noted that all passage ways are free and clear of obstacles. LPA's conducted a sample medication audit. LPA's reviewed all staff and resident files. LPA's noted and cited for no lamp or lighting fixture in Bedroom #3 (CCL,87303(d)), black mold in the bathtub in bathroom number #1 (CCL, 87303(e)(6)), Staff bedroom was left unsecured with vitamins in view and unsecured. (CCL, 87309(c)), and no recent documented fire drill. (H&S 1569.695(c)). LPA's conducted a full review of the annual facility care tools. Exit interview, report read, appeal rights and report provided.

Kelly Burley	TELEPHONE: (805) 562-0413
Mark Jeffries	TELEPHONE: (805)562-0400
	DATE: 03/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 03/27/2025 05:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AVE'S BOARD AND CARE	FACILITY NUMBER: 421703043
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(d)

Maintenance and Operation

(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation the licensee did not comply with the section cited above in bedroom #3, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2025
	Plan of Correction
1 2 3 4	Administrator will provied proof by photopgraph of lamp or lighting in bedroom #3 on or before 04/08/2025.

Type B

Section Cited

CCR

87303(e)(6)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation and photograph, the licensee did not comply with the section cited above in bathroom #1] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2025
	Plan of Correction
1 2 3 4	Adminsitrator will show proof that tub in bathroom #1 is throughtly cleaned and free of mold and dirt by 04/08/2025. proof by photo emaied to LPA.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Kelly Burley	TELEPHONE: (805) 562-0413
Mark Jeffries	TELEPHONE: (805)562-0400
	DATE: 03/25/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/27/2025 05:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AVE'S BOARD AND CARE	FACILITY NUMBER: 421703043
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87309(c)

Storage Space and Access

(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA'sobservation, the licensee did not comply with the section cited above in one count of unsecured medications which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2025
	Plan of Correction
1 2 3 4	Staff traing on locking the door to be completed and emplemented on or before 04/08/2025, LPA to be emailed traing roster and singed aknowlagement by staff of need to keep staff bedroom secure at all time.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2025
	Plan of Correction
1 2 3 4	Facility will conduct an emergency drill asap and email LPA of requiored drill elements on or before 04/08/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Kelly Burley	TELEPHONE: (805) 562-0413
Mark Jeffries	TELEPHONE: (805)562-0400
	DATE: 03/25/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025

LIC809 (FAS) - (06/04)

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