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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703121
Report Date: 12/29/2025
Date Signed: 12/29/2025 10:36:25 AM

Document Has Been Signed on 12/29/2025 10:36 AM - 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:CASA JUANA MARIAFACILITY NUMBER:
421703121
ADMINISTRATOR/
DIRECTOR:		JENNIFER GODDARDFACILITY TYPE:
735
ADDRESS:106 JUANA MARIA AVENUETELEPHONE:
(805) 963-5021
CITY:SANTA BARBARASTATE: CAZIP CODE:
93103
CAPACITY: 6CENSUS: 4DATE:
12/29/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:04 AM
MET WITH:Administrator, Jennifer GoddardTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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 At 9:00am on 12/29/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct a health and welfare check for clients currently residing in this facility. LPA met with Administrator, Jennifer Goddard, announced who he is and the reason for the visit. LPA noted that there were no client present at the facility during the time of the visit. Administrator stated that all 4 Clients are currently at the Mental Wellness Center. Administrator stated that all 4 Clients can leave the facility unassisted according to the facilities Plan of Operations and the Clients Physicians Report (LIC602). Administrator stated that there is no specific daily schedule for the Clients and at any give time may be at the facility, in the community or at the Mental Wellness Center. Administrator stated that all 4 Clients are currently safe and operating in their normal dally routines.
Administrator and LPA discussed the reporting requirements for the incidents that took place on 10/28/2025, and 12/16/2025. Administrator stated that in both cases her due diligence was to contact local law enforcement and make initial reporting call to CCLD. Administrator stated that she called licensing to report the first incident on 10/20/2025 at 1:59pm, which was verified by LPA's cell phone record. Administrator stated that pertaining to the incident on 12/16/2025, she made phone contact on 12/26/2025 at 2:02pm, with LPA Kristin Kontilis which was visually verified by LPA Jeffries observing Administrators phone records. LPA noted that both written reports to licensing were submitted by Administrator with the admission of the Administrator on 12/26/2025. As both of these incident reports containing the information specified were submitted late, (Incident dated 10/18/2025, late by 61 days; Incident dated 12/16/2025 late by 3 days) a citation for not submitted a written report, within seven days following the occurrence of such event, is issued (80061(b), reporting requirements) with this report. Administrator and LPA reviewed and educated on CCLD regulations reporting requirements.
Exit interview, report read, citation issued, appeal rights and report provided.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Mark Jeffries
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2025
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 12/29/2025 10:36 AM - It Cannot Be Edited


Created By: Mark Jeffries On 12/29/2025 at 10:09 AM
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: CASA JUANA MARIA
FACILITY NUMBER: 421703121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2025
Section Cited
CCR
80061(b)

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80061 Reporting Requirements (b)Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information
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Administrator will conduct staff training for this facility on reporting requirements for CCLD regulations and Health and Welfare regulations regarding this facility type. Administrator will email LPA Jeffries copy of the training with dates and participants by 01/08/2025
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specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. This requirement was not met by evidence of late reporting and admission, which poses a potential risk for clients in care.
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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
NAME OF LICENSING PROGRAM MANAGER:
Mark Jeffries
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2025


LIC809 (FAS) - (06/04)
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