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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801580
Report Date: 08/03/2022
Date Signed: 03/21/2023 09:19:34 AM


Document Has Been Signed on 03/21/2023 09:19 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:ABUNDANT CARE IIIFACILITY NUMBER:
425801580
ADMINISTRATOR:DANIEL BONDFACILITY TYPE:
740
ADDRESS:4589 AUHAY DRIVETELEPHONE:
(805) 845-8490
CITY:SANTA BARBARASTATE: CAZIP CODE:
93110
CAPACITY:6CENSUS: DATE:
08/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:AMENDED REPORT SENT VIA EMAILTIME COMPLETED:
02:55 PM
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This is a report issued to change a citation issued on 8/3/2022 from a Type A to a Type B citation. Please refer to the 8/3/2022 report for additional information.
Amended Report emailed to Administrator for signature.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
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 2


Document Has Been Signed on 03/21/2023 09:19 AM - It Cannot Be Edited

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: ABUNDANT CARE III
FACILITY NUMBER: 425801580

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2022
Section Cited

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87468.1 (a)(2) Personal Rights of Residents in all Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
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Licensee agrees to schedule infection control training, including mask requirements, for all staff by 8/5/2022. Training will be completed and provide proof of training with staff signatures by 8/5/2022.
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Based on LPA’s observation, the licensee did not comply with regulation above when Staff 1 and Staff 2 were present in the facility without wearing masks which poses a potential health, safety, and personal rights risk to residents 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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
LIC809 (FAS) - (06/04)
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