<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801562
Report Date: 10/13/2023
Date Signed: 10/13/2023 03:13:43 PM

Document Has Been Signed on 10/13/2023 03:13 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:ST. ANDREW'S RESIDENCE IIFACILITY NUMBER:
425801562
ADMINISTRATOR:CHARMAINE R. ABATAFACILITY TYPE:
735
ADDRESS:1124 WEST EL CAMINO STREETTELEPHONE:
(805) 361-0255
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 6CENSUS: 6DATE:
10/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Charmaine Abata, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Olson conducted an unannounced Case Management- Incident visit to the facility above. LPA was accompanied by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Miguel Magana. LPA and QAS met with Administrator and explained the purpose of the visit.

CCL received an incident report on 10/06/23 stating that on 10/04/23 Staff observed bruises on Client 1 (C1) on both sides of their body, behind the knee and private area. When staff asked where the bruises were from C1 stated they fell at their previous facility and took C1 to the doctor. Incident report stated C1 moved into the current facility on 10/02/2023.

LPA toured the facility,interviewed staff, resident and reviewed documents.

Interviews with staff revealed C1 has had the same story about the bruises, even 2 weeks later. Administrator said they took C1 to their Primary Care Physician (PCP) on 10/5/23 to look at the bruises and to the ER on 10/7/23 due to pain. Administrator also stated they have been taking C1 to specialists to get checked out. C1 stated to LPA and QAS they got the bruises from a fall at their last facility. LPA asked if C1 was abused or if anyone ever hurt them and C1 said no. C1 stated they like it here and staff treat C1 a lot better and nicer than their previous facility.

No deficiencies were noted.
Exit interview conducted copy of the report issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2023
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 1