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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703604
Report Date: 06/12/2024
Date Signed: 06/12/2024 12:53:45 PM


Document Has Been Signed on 06/12/2024 12:53 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:ORCUTT BOARD AND CARE HOMEFACILITY NUMBER:
421703604
ADMINISTRATOR:ANNIE YAGUEFACILITY TYPE:
740
ADDRESS:263 CRESCENT AVE.TELEPHONE:
(805) 934-2586
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:6CENSUS: 6DATE:
06/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Annie Yague, Licensee/AdministratorTIME COMPLETED:
10:00 AM
NARRATIVE
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On 06/12/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a case management-deficiencies visit. During the complaint investigation of complaint # 29-AS-20231201163837, the following deficiencies were observed:

There were no incident reports submitted for R1’s hospitalization on 08/11/2023 or 10/27/2023. On 10/27/2023, the licensee notified R1’s resident representative that R1 was hospitalized due to passing out at the dining room table. However, the licensee did not notify R1’s representative of R1’s 10/26/2023 fall at the facility.

Exit interview, deficiencies cited, report given, appeal rights given.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
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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Document Has Been Signed on 06/12/2024 12:53 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ORCUTT BOARD AND CARE HOME
FACILITY NUMBER: 421703604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2024
Section Cited
CCR
87211(1)(B)

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87211(1)(B) Reporting Requirements. Licensee shall furnish to licensing agency reports...including following…(1) Written report submitted to agency and responsible person...seven days of occurrence of events (A) through (D)...(B)... injury determined by physician...under facility supervision.
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The licensee will submit a plan describing how facility will ensure reporting requirements are followed. Submit proof to CCL by 7/10/2024.
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Requirement not met as evidenced by: Based on interviews and records review, licensee did not comply by not submitting incident reports for R1 on 08/11/2023, 10/27/2023 nor notifying representative of R1 on 10/26/2023, which posed a potential health and safety risk to residents 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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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