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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801936
Report Date: 09/08/2022
Date Signed: 09/08/2022 05:01:28 PM

Document Has Been Signed on 09/08/2022 05:01 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:MOSHE DAVISFACILITY TYPE:
735
ADDRESS:572 INGER DRIVETELEPHONE:
(714) 306-4068
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 6CENSUS: 4DATE:
09/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Moshe Davis, Administrator and Mihaela Bauer, LicenseeTIME COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst's (LPA's) Olson and Cortez conducted a Case Management visit to address the deficiencies noted during complaint control # 29-AS-20220831122413 investigation visit conducted on 9/8/2022.

Upon entry into the facility LPA's observed that Administrator and a guest were not wearing a mask. At approximately 3:05 PM LPA Olson observed Licensee walk into the facility without a mask and it took Licensee a few minutes to find a mask and put it on.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):


Exit interview conducted, today's report and appeal rights were reviewed and emailed to Administrator and Licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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 09/08/2022 05:01 PM - It Cannot Be Edited


Created By: Jeannette Olson On 09/08/2022 at 04:48 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: 09/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2022
Section Cited
CCR
87468.1

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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 9/9/2022. Training will be completed and provide proof of training with staff signatures will be sent to CCL by 9/9/22.
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Based on LPA’s observation, the licensee did not comply with regulation above when 2 staff and a guest were present in the facility without wearing masks which poses an immediate 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 Burley
LICENSING EVALUATOR NAME:Jeannette Olson
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022


LIC809 (FAS) - (06/04)
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