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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801562
Report Date: 07/29/2024
Date Signed: 07/29/2024 04:42:44 PM

Document Has Been Signed on 07/29/2024 04:42 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ST. ANDREW'S RESIDENCE IIFACILITY NUMBER:
425801562
ADMINISTRATOR/
DIRECTOR:		CHARMAINE R. ABATAFACILITY TYPE:
735
ADDRESS:1124 WEST EL CAMINO STREETTELEPHONE:
(805) 361-0255
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 6CENSUS: 6DATE:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Angeles PimentelTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Melisa Rankin arrived unannounced to conduct a one year required annual. LPA met with Assistant Administrator Angeles Pimentel and explained the reason for the visit.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and to ensure the facility is in compliance with Title 22 Regulations.

Kitchen: The kitchen area was observed. The facility has a sufficient supply of non-perishable and perishable food items. Cleaning supplies and disinfectants are stored in the garage, inaccessible to clients. Knives are stored in a locked cabinet in the kitchen.

Common areas: Living and dining room furniture were observed to be in good condition. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced 2/12/2024.

The backyard has a covered outdoor area equipped with furniture for client use. No bodies of water noted. The washer and dryer are in the garage. The garage is not locked.

Restrooms: The two client restrooms were clean and sanitary and in operating condition with non-skid surfaces/mats. The bathrooms were sufficiently stocked with soap and paper towels. Hot water temperature measured in the client restroom was slightly above regulation, a suggestion to start a monthly water temperature log was suggested to ensure temperature remains in regulations.

Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ST. ANDREW'S RESIDENCE II
FACILITY NUMBER: 425801562
VISIT DATE: 07/29/2024
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Bedrooms: There are four (4) client rooms, which were furnished with appropriate linens and required furniture. A linen closet was located outside of the rooms, which stocked extra linens and towels.

Records: LPA reviewed client and staff records at 3:00 p.m. LPA reviewed a sampling of client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and needs and services plan. All files were complete.

LPA reviewed a sampling of staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 3 home. The last disaster drill was conducted in May of 2024.

Medications: Medications review began at 2:30 p.m.; medications are centrally stored and locked in a closet next to the kitchen. Medications are labeled and checked for expiration dates. LPA advised the Administrator to ensure that all the necessary information is properly documented on the CSMDR.

Infection Control: The facility has an infection control plan. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is adequate.

Exit interview conducted. A copy of the report was printed and emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC809 (FAS) - (06/04)
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