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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703604
Report Date: 03/13/2025
Date Signed: 03/13/2025 02:01:50 PM

Document Has Been Signed on 03/13/2025 02:01 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:ORCUTT BOARD AND CARE HOMEFACILITY NUMBER:
421703604
ADMINISTRATOR/
DIRECTOR:		ANNIE YAGUEFACILITY TYPE:
740
ADDRESS:263 CRESCENT AVE.TELEPHONE:
(805) 934-2586
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 6CENSUS: 6DATE:
03/13/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Licensee, Annie Yage.TIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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 At 2:05pm on 03/13/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to conduct a Case Management visit pertaining to cross report of form SOC 341 for resident 1 (R1) dated 03/16/2025. LPA met with Licensee Annie Yague, announce who he is and the reason for the visit.

LPA conducted a health and welfare check of R1. LPA requested R1’s physicians report (LIC602), Hospice Care contract, Medication Administration Record (MAR) and Centrally Stored Medication Record. (CSMR) LPA conducted interviews of staff, residents and family members.

LPA noted that the Family member 1 (F1) was present during the case management visit and is the Power of Attorney for R1 and noted that the care at the facility was excellent and was noted in interview LIC812. LPA noted that he was informed that the Santa Barbara County Sheriffs (SBCOS) were at the facility on 03/11/2025 for same SOC 341 cross report. LPA will obtain SBCOS case number at a later date.

LPA had no significant findings during the visit. .

Exit interview, report read, and report provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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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