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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801511
Report Date: 08/14/2024
Date Signed: 08/20/2024 08:16:36 AM

Document Has Been Signed on 08/20/2024 08:16 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MI CASAFACILITY NUMBER:
425801511
ADMINISTRATOR/
DIRECTOR:		SANDRA Y.LOPEZ-MARTINEZFACILITY TYPE:
735
ADDRESS:1307 SAN ANDRES STREETTELEPHONE:
(805) 966-0230
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY: 6CENSUS: 4DATE:
08/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:08 AM
MET WITH:Sandra Lopez-MartinezTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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A Case Management visit was conducted to address deficiencies noted during Complaint Control #29-AS-20240813104110 investigation visit conducted during today’s visit. Upon arrival at approximately 11:08 am, observation revealed the “Ring” doorbell is not audible to staff present inside the facility and did not notify Administrator who was out of the facility at the time of LPA’s arrival. At approximately 11:58 am, Tracy Jackson, Lead Quality Assurance Specialist, Tri-Counties Regional Center (TCRC) confirmed the doorbell is not properly working. Witness 1 (W1) stated the battery needs to be charged and plugged the battery in to begin charging it. Administrator stated the issue is that the doorbell is not connected through the internet.
At approximately 11:45 am, LPA observed the kitchen floor with debris, candy wrapper, food particles, and a fork. S1 stated they are on duty one day/week and their duties include cleaning the facility. S1 stated they are the only staff who has the responsibility of cleaning the facility. At approximately 12:50 pm, LPA observed numerous items such as stacks of paperwork, boxes, surgical masks, decorations, and containers with miscellaneous items stacked amongst a couch, on the desktop, under counters, in corners, and along the wall leading into the facility.
At approximately 2:11 pm, LQAS and LPA observed medications in the refrigerator one box of Ozempic 20mg per dose, two boxes of Repatha 140MG/ML Sureclick 2=2 prescribed to Administrator and two boxes of Humalog Kwik-Pen insulin lispro injection with no label. Medications were observed unlocked on the refrigerator door and in the vegetable drawer.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties.



Exit interview conducted. A copy of the report and appeal rights were provided at the time of the visit.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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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Document Has Been Signed on 08/20/2024 08:16 AM - It Cannot Be Edited


Created By: Kristin Kontilis On 08/14/2024 at 03:20 PM
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: MI CASA
FACILITY NUMBER: 425801511

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2024
Section Cited
CCR
80075(k)(1)

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80075(k)(1) Health Related Services: (k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Licensee agrees to purchased a lock box for the refrigerator to be delivered by 8/15/2024.
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This requirement is not met as evidenced by:
Based on observation and interview, the licensee did not comply with the section cited above when prescribed medications were observed in the facility refrigerator which poses an immediate health, safety, or personal rights risk to persons in care.
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Type B
08/19/2024
Section Cited
CCR80087(a)

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80087(a) Buildings and Grounds: The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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Licensee agrees to provide a cleaning schedule and checklist for staff and Administrator. Licensee agrees to submit current LIC500. Licensee will submit proof of office area cleaned and organized. Licensee will submit via email no later than the POC due date.
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Based on observation, the licensee did not comply with the section cited above when the facility was unclean, the doorbell was inoperable, and cluttered which poses a potential health, safety or personal rights 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 Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
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