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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703322
Report Date: 09/01/2023
Date Signed: 09/01/2023 01:53:24 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/01/2023 01:53 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:HELEN'S RESIDENCEFACILITY NUMBER:
421703322
ADMINISTRATOR:HELEN SAN ANTONIO 98FACILITY TYPE:
735
ADDRESS:1653 N ALISONTELEPHONE:
(805) 925-6484
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 6CENSUS: 3DATE:
09/01/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Joni San Antonio, Backup AdministratorTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Jenny Olson arrived unannounced to conduct a Case Management Annual Continuation Visit. LPA met with Backup Administrator and explained the reason for the visit.

Kitchen: The kitchen area was observed at 10:20 a.m. The facility has a sufficient supply of non-perishable but could use more perishable food items. Cleaning supplies and disinfectants are stored in the garage, inaccessible to clients. Knives are stored in a cabinet in the kitchen.

Common areas: Living and dining room furniture were observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. At 10:30 a.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced 12/20/2022.

The backyard has a covered outdoor area equipped with furniture for client use. No bodies of water noted. The washer and dryer are in the garage. The garage is not locked.

Restrooms: The two client restrooms were in operating condition with non-skid mats. The bathrooms were sufficiently stocked with soap and paper towels. Around 10:35 a.m., the hot water temperature measured in the client restroom at 115.1 degrees Fahrenheit.

Bedrooms: There are four (4) client rooms, which were furnished with appropriate linens and required furniture. A linen closet was located outside of the rooms, which stocked extra linens and towels.

Medications: Medications review began at 11:15 a.m.; medications are centrally stored and locked in a cabinet in the kitchen. Medications are labeled and checked for expiration dates.
Continued on 809-C.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2023
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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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: HELEN'S RESIDENCE
FACILITY NUMBER: 421703322
VISIT DATE: 09/01/2023
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Infection Control: The facility has an infection control plan, The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol needs to be improved. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

At 1:20 p.m. LPA interviewed one staff and one resident who were present at the time.

Exit interview conducted. A copy of the report was printed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
LIC809 (FAS) - (06/04)
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