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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801936
Report Date: 07/29/2024
Date Signed: 07/29/2024 02:47:38 PM

Document Has Been Signed on 07/29/2024 02:47 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:BAUER RESIDENTIAL SANTA MARIA 4FACILITY NUMBER:
425801936
ADMINISTRATOR/
DIRECTOR:
MOSHE DAVISFACILITY TYPE:
735
ADDRESS:572 INGER DRIVETELEPHONE:
(714) 306-4068
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 6CENSUS: 4DATE:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Administrator, Jamie StaineTIME VISIT/
INSPECTION COMPLETED:
03:31 PM
NARRATIVE
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At 11:50am on 07/29/2024, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conduct the annual facility inspection. LPA met with Administrator, Jamie Staine, announced who he is and the reason for the visit. Tri Counties Regional Center (TCRC) Quality Assurance, Vince Figueroa (QA) was currently at the facility conducting an annual facility inspection for TCRC.
Administrator, QA and LPA toured facility The facility is maintained in conformance with state fire marshal regulations. Smoke detectors and carbon monoxide detectors functioning. Fire extinguisher was fully charged. Inside and outside passageways are free from obstruction. Facility has a backyard for resident use with furniture and shade available. The facility temperature was 70 degrees F. Hot water temperature tested was within regulation parameters. Residents’ rooms are appropriately furnished with adequate lighting. LPA observed an adequate amount of perishable and non-perishable food. Food is stored in appropriate containers in the refrigerator and freezer. A current emergency disaster and infection control plan is updated and available. Administrator is on the premises an adequate amount of hours to manage and oversee the facility. Disaster drills are conducted frequently. QA and LPA reviewed medications and Centrally Stored Medication Records (CSMR). Medications are stored in a locked cabinet. There is a signed and dated order from a physician for prescription and PRN medication. LPA reviewed a sample of client CSMR, and medications are given per physician's orders. QA and LPA reviewed client and staff files. All client files reviewed have current physicians report, current needs and services plans and admission agreements. Staff files reviewed had current first aid certificates, health screenings and adequate training hours. LPA noted that facility twin stove is broken and the kitchen counter-top at the kitchen sink is cracked, both addressed with citation on plan to repair or replaced.
Administrator and LPA conducted a full review of the annual care tools module. LPA noted that there were no citations noted during the care tools review and one citation noted in the full facility physical tour as outlined above. LPA advised Administrator to turn in change of Administrator packet as soon as possible to update current administrator.
Exit interview, one deficiency cited, appeal rights and report given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
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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Document Has Been Signed on 07/29/2024 02:47 PM - It Cannot Be Edited


Created By: Mark Jeffries On 07/29/2024 at 02:31 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: BAUER RESIDENTIAL SANTA MARIA 4

FACILITY NUMBER: 425801936

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 counts of facility in disrepair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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Administrator agrees to repair or replace facility stove and counter-tops to safe and working conditions by 08/12/2024. Administrator will email LPA's (mark.jeffries@dss.ca.gov and erika.miller@dss.ca.gov) of repaired or replaced items..
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Burley
LICENSING EVALUATOR NAME:Mark Jeffries
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024


LIC809 (FAS) - (06/04)
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