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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801511
Report Date: 02/14/2024
Date Signed: 02/14/2024 03:31:29 PM

Document Has Been Signed on 02/14/2024 03:31 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:MI CASAFACILITY NUMBER:
425801511
ADMINISTRATOR:SANDRA Y.LOPEZ-MARTINEZFACILITY TYPE:
735
ADDRESS:1307 SAN ANDRES STREETTELEPHONE:
(805) 966-0230
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY: 6CENSUS: 4DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Sandra Lopez-Martinez, AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection visit to the above-named facility. LPA met with Sandra Y. Lopez-Martinez, Administrator and explained the purpose of the visit. Tracy Jackson, Quality Assurance Lead Specialist, Tri-Counties Regional Center accompanied LPA on the visit.
The facility currently has four (4) residents residing in the facility. At the time of arrival, there was one resident in the facility and two staff on duty. Administrator Lopez-Martinez was present in the facility at the time of arrival.
LPA conducted a physical tour of the facility. The facility is a one-story home to residents with intellectual disabilities. The facility contracts with Tri-Counties Regional Center.
The facility has 2 private bedrooms, 1 shared bedroom, and 2 shared bathrooms for 4 residents and 2 live-in staff. Each bedroom has a bed, nightstand, and lights and nightstand lamps to provide sufficient lighting.
The front yard consists of concrete steps and concrete walkways. The backyard has a patio with outdoor furniture. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. A locked shed is located at the back of the home.
LPA and QAS Specialist observed multiple items stacked and piled in various areas of the backyard and patio. Items include exercise equipment, washing machine, walkers, rugs, floor mats, wastebasket, plastic bag with shoes, wires, and gardening supplies.
LPA and Tri-Counties Regional QAS Specialist observed expired canned goods, an expired box of breakfast cereal, and an opened box of cake mix not properly packaged.
LPA and Tri-Counties Regional QAS Specialist observed items such as bags of clothing, purses, shoes, and other miscellaneous items stored in Resident 1’s (R1’s) room. Administrator Lopez-Martinez stated the items do not belong to R1.

Please continue to 809-C, Pg 2.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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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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: MI CASA
FACILITY NUMBER: 425801511
VISIT DATE: 02/14/2024
NARRATIVE
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 LPA and Tri-Counties Regional QAS Specialist observed fire extinguisher was recently purchased on 10/1/2023, carbon monoxide detector and smoke alarms are in good working order.
LPA and Tri-Counties Regional QAS Specialist determined residents’ medications are given as prescribed.
All staff associated with the facility have a criminal record clearance.

Due to time restraints, LPA will return at a later date to continue to inspection.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in 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: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/14/2024 03:31 PM - It Cannot Be Edited


Created By: Kristin Kontilis On 02/14/2024 at 03:01 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: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80061(b)
Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above when licensee did not report to CCLD that R4 had lost a tooth which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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POC: Licensee agrees to submit written understanding of 80061 in its entirety. Licensee agrees to attend Tri-Counties Regional Center upcoming incident reporting training.
Type A
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews conducted, the licensee did not comply with the section cited above when several expired and improperly packaged food items were removed from the food pantry which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee agrees to conduct a thorough inventory of all foods in the food pantry, including emergency foods to ensure no expired foods are present. Licensee agrees to provide a plan in place as to how facility staff will ensure compliance of this regulation.
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: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
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