<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703604
Report Date: 12/03/2021
Date Signed: 12/03/2021 04:12:11 PM

Document Has Been Signed on 12/03/2021 04:12 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:ANNIE YAGUEFACILITY TYPE:
740
ADDRESS:263 CRESCENT AVE.TELEPHONE:
(805) 934-2586
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 6CENSUS: 3DATE:
12/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Administrator Annie YagueTIME COMPLETED:
12:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/3/21 at 10:00 AM, Licensing Program Analyst (LPA) Toan Luong conducted an unannounced 10-day complaint visit to the facility. LPA met with Administrator Annie Yague and explained the purpose of the visit. During complaint visit, LPA was denied access to one room. Administrator informed LPA that room was locked by staff who was not present at the facility. Another door was also locked, and LPA did not have access to the room. Administrator did not have key copy available.

LPA issued citation. Appeal rights and copy of the report emailed to administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/03/2021 04:12 PM - It Cannot Be Edited


Created By: Toan Luong On 12/03/2021 at 11:26 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: ORCUTT BOARD AND CARE HOME
FACILITY NUMBER: 421703604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2021
Section Cited
CCR
87755(a)

1
2
3
4
5
6
7
87755 Inspection Authority of the Licensing Agency (a) Any duly authorized officer, employee or agent of the licensing agency may...inspect the entire premise of any place providing services at any time, with or without advance notice. This requierment was not met by: LPA was not granted access to one room and one locked door.
1
2
3
4
5
6
7
Facility will have a spare key

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 Burley
LICENSING EVALUATOR NAME:Toan Luong
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2