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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703635
Report Date: 06/14/2022
Date Signed: 06/14/2022 04:49:01 PM


Document Has Been Signed on 06/14/2022 04:49 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:DANELLE'S GUEST HOME IFACILITY NUMBER:
421703635
ADMINISTRATOR:COMETA, NONAFACILITY TYPE:
740
ADDRESS:4866 FRANCES STTELEPHONE:
(805) 967-5237
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:6CENSUS: 4DATE:
06/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Nona Cometa, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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This Case Management visit was conducted to address the deficiencies noted during Complaint Control #29-AS-20210512161156 investigation visit conducted on 6/14/2022. LPA met with Administrator Nona Cometa and explained the purpose of the visit.

On 5/14/2021, 7/22/2021, and 6/14/2022, LPA interviewed administrator and Staff 1 (S1). On 5/14/2021, LPA conducted an interview with Resident 1 (R1). On 7/22/2021, LPA obtained documents pertaining to this visit.
On 6/14/2022, Administrator stated R1 was a family member who resided in the facility beginning on or about March 3, 2021 until October 4, 2021. Administrator stated R1 was living in the facility as a family member. Administrator stated she did not request a live-scan for R1 or associate R1 to the facility until after a visit was conducted by Marco Quintanar, Long-Term Care Ombudsman Supervisor and LPA K. Kontilis on 5/14/2021.
On 6/14/2022, LPA reviewed Licensing Information System (LIS), California Department of Social Services criminal clearance record database and confirme R1 was associated to the facility on 5/19/2021.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Civil penalties assessed in the amount of $500.00.

Exit interview conducted. Today’s report,, civil penalties and Appeal Rights were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
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 06/14/2022 04:49 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: DANELLE'S GUEST HOME I
FACILITY NUMBER: 421703635

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2022
Section Cited

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87355(e)(2) Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355...
This requirement is not met as evidenced by:
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as R1 was residing in the facility as a family member and was not given a background clearance or associated to the facility which poses an immediate safety risk to persons 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: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
LIC809 (FAS) - (06/04)
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