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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800215
Report Date: 03/19/2024
Date Signed: 03/19/2024 11:27:30 AM

Document Has Been Signed on 03/19/2024 11:27 AM - 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:MCMILLAN RANCHFACILITY NUMBER:
425800215
ADMINISTRATOR:MARTHA MANCHAFACILITY TYPE:
735
ADDRESS:3840 ORCUTT GAREY ROADTELEPHONE:
(805) 937-2826
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 10CENSUS: 9DATE:
03/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Martha Mancha, Administrator and Mary Ellen, Residential CounselorTIME COMPLETED:
12:00 PM
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On 03/19/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced Case Management - Incident visit to the facility above. LPA met with Administrator Martha Mancha and Residential Counselor Mary Ellen and explained the purpose of the visit.

During the visit on 03/19/2024, LPA observed the facility as well as the Clients in care. LPA conducted record review of documents pertinent to the Case Management Incident. LPA requested the following documents: Client File including most current Physician’s Report, Admission Agreement, most current Regional Center Individual Program Plan (IPP) assessment and/or Appraisal/Needs and Services Plan, most recent Behavior assessment from Regional Center if applicable, hospital visit reports, medical visit reports, facility internal/charting notes on Client, and Emergency/Identification Information. LPA requested LIC 500/Current Staff schedule as of March 2024, reviewed staff member clearance by the Department of Justice (DOJ), Staff member write-ups (positive or negative) if applicable, and LPA received documentation of contact information for Staff members. An Investigations Branch (IB) Service Request referral was submitted on 03/18/2024 and accepted by IB on 03/18/2024.

LPA informed the Administrator additional time will be needed for the investigation. LPA will return at a later time as further investigation is needed.

Exit interview conducted. Copy of the report provided to the facility.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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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