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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703322
Report Date: 02/07/2024
Date Signed: 02/07/2024 01:02:34 PM

Document Has Been Signed on 02/07/2024 01:02 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: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:
02/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Joni San Antonio, Backup AdministatorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Olson conducted an unannounced Case Management Incident visit. LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Vincent Figueroa. During today’s visit, LPA met with Backup Administrator and explained the reason for the visit.

CCL received information about an incident that allegedly took place in the facility, involving Client 1 (C1). LPA and QAS toured the facility, interviewed staff and clients, and requested relevant documents.

LPA will return at a later date if warranted.

Exit interview conducted, copy of report issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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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