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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801866
Report Date: 05/19/2021
Date Signed: 05/19/2021 02:55:03 PM

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:MISSION VILLAFACILITY NUMBER:
425801866
ADMINISTRATOR:LISA G. GERRFACILITY TYPE:
740
ADDRESS:321 WEST MISSION STREETTELEPHONE:
(805) 898-2709
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:14CENSUS: 13DATE:
05/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lisa Gerr, Administrator; Dana Newquist, LicenseeTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Mark Jeffries and Kristin Kontilis conducted an onsite one-year infection control annual visit to the above-named facility. LPAs met with Lisa Gerr, Administrator and Dana Newquist, Licensee and explained the purpose of the visit.
LPAs conducted a physical tour of the facility. The facility has submitted a Mitigation Plan to the Department. The facility has an entry station at the front of the building. Upon entry, staff, visitors, and residents returning from an outing are required to sign-in, complete a symptom questionnaire, and have a temperature screening. All documentation is kept on a clipboard and filed in a binder on a daily basis. The entry station has PPE gear, hand sanitizer, and disinfecting wipes along with a thermometer.
The facility consists of a large common area used for dining and activities. LPAs discussed options of resident cohorts to ensure social distancing best practices. Equipment and supplies are kept in locked cabinet located in the hallway of the facility.
The kitchen, living room, and dining area are neat and clean. The kitchen consists of a refrigerator, freezer, stove/oven, microwave, coffee makers, toasters, fresh juice machine, mixer/blender, waffle iron, and two dishwashers. LPA observed a lockable gate denying access to the kitchen. LPAs recommended magnetic locks on kitchen drawers. Sharps are kept in a locked closet in the hallway.
Screening of residents for symptoms and temperature checks is conducted at every medication check which consists of 2-4 times per day. Facility staff monitor residents for change of condition. Increased monitoring is conducted if a change of condition is noted of any residents showing COVID-19 symptoms, or signs of a fever.
Signs are posted on hallway bulletin boards stating COVID-19 symptoms should be reported to staff, Administrators, and LIcensee.
There are twelve bedrooms and five bathrooms. The bathrooms have secure grab bars and no skid flooring. The room temperature in the facility was measured at a comfortable temperature at 12:05 pm.
All persons associated with the facility have criminal background clearance.
The trash, recycling, and green waste bins are standard bins with flip lids. There are no bodies of water.
Exit interview conducted. No citations issued. Copy of the report has been given.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2021
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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