421703748-2-24-2025-29-AS-MJES-DE7TS6-20250224135839

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 421703748
Report Date: 02/24/2025
Date Signed: 02/24/2025 02:01:58 PM

Document Has Been Signed on 02/24/2025 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:	PURISIMA HILLS		FACILITY NUMBER:	421703748
ADMINISTRATOR/ DIRECTOR:	SUSAN MARSH		FACILITY TYPE:	740
ADDRESS:	237 ALDEBARAN AVENUE		TELEPHONE:	(805) 733-4395
CITY:	LOMPOC	STATE: CA	ZIP CODE:	93436
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	02/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:32 AM
MET WITH:	Administrator, Susan Marsh		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

NARRATIVE

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At 09:20am on 02/24/2025, Licensing Program Analysts (LPA) Mark Jeffries and Garrett Haner-Tomasko arrived at the facility to conduct an unannounced annual inspection. LPAs met with Licensee Susan Marsh. Announced who they are and the reason for the visit being the facility annual inspection.

LPAs toured facility with Licensee. The facility has 3 single occupancy and 1 double occupancy bedrooms and 3 bathrooms. The facility is maintained in conformance with state fire marshal regulations. Smoke detectors are functioning throughout the facility. Fire extinguisher is fully charged and serviced this month. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 71 degrees F. Water temperatures were noted to be within 105-120 (f). Residents’ rooms are appropriately furnished with adequate lighting. LPA observed more than two days of perishable and more than seven days of non-perishable food. An Emergency and Disaster Plan and Personal Rights are available and located on the facility kitchen wall.

Staff files reviewed. LPA's reviewed Emergency Disaster Plan and Infection Control Plan. LPA reviewed medications. Medications are stored in a locked cabinet in the dining room and refrigerator locked in the bedroom closet.

During tour of the facility the carbon monoxide detector was noted to be non-functioning, the bath/shower in the hallway bathroom was non-functioning with the water outlet to the tub plugged, and nails were noted to be sticking out of the outside ramp on the west side of the facility, While observing food in the kitchen refrigerator moldy vegetables and an uncovered bowel of cauliflower were cited on the annual care tool.

Exit interview, report read, citations issues, appeal rights report provided..

Kelly Burley	TELEPHONE: (805) 562-0413
Mark Jeffries	TELEPHONE: (805)562-0400
	DATE: 02/24/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025

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 9

Document Has Been Signed on 02/24/2025 02:01 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: PURISIMA HILLS	FACILITY NUMBER: 421703748
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Kelly Burley	TELEPHONE: (805) 562-0413
Mark Jeffries	TELEPHONE: (805)562-0400
	DATE: 02/24/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025

LIC809 (FAS) - (06/04)

Page: 2 of 9

Document Has Been Signed on 02/24/2025 02:01 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: PURISIMA HILLS	FACILITY NUMBER: 421703748
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

87555(b)(23)

General Food Service Requirements

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Kelly Burley	TELEPHONE: (805) 562-0413
Mark Jeffries	TELEPHONE: (805)562-0400
	DATE: 02/24/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025

LIC809 (FAS) - (06/04)

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