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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801990
Report Date: 11/01/2023
Date Signed: 11/09/2023 03:12:32 PM

Document Has Been Signed on 11/09/2023 03:12 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:CAREMERIDIANFACILITY NUMBER:
425801990
ADMINISTRATOR:ADAN RUBALCAVAFACILITY TYPE:
735
ADDRESS:1135 N PATTERSON AVETELEPHONE:
(805) 683-1995
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY: 6CENSUS: 5DATE:
11/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Nicole Dominguez, Interim AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Required visit and inspection of the facility. LPA arrived at 11:30 AM and was greeted by Nicole Dominguez, Interim Administrator. LPA explained the purpose of the visit. At the time of arrival, there were (5) staff on duty and (5) residents in care. LPA informed Administrator of the visit.

Entrance interview conducted.
There are currently five (5) residents residing in the facility. The facility is a one-story facility for residents with neurological injuries.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA conducted a physical tour of the facility for fire safety, personal accommodations, and food service.
The physical environment was checked for cleanliness and condition. The kitchen, living room, and dining area are neat and clean. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. The facility maintains a comfortable temperature.
Fire inspection was current as of 10/19/2023. The dual carbon monoxide/smoke alarm system are in good working order.
The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean.
Activities include physical therapy, speech therapy, and occupational therapy. Additionally, residents participate in planning activities including outdoor excursions to local businesses and eateries, movies, museums, parks, walks on the beach, and other local attractions.

Please continue to 809-C, Pg 2.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CAREMERIDIAN
FACILITY NUMBER: 425801990
VISIT DATE: 11/01/2023
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 The facility has 2 shared bedrooms and 2 single bedrooms. Each bedroom has a single bed, nightstand, and nightstand lamps to provide sufficient lighting. The business office and administrator’s office are located off the facility driveway away from the main part of the common areas. Medications, residents’ records, and personnel records are kept in the business office in locked cabinets.
LPA toured the outside area which included various shaded and non-shaded garden areas, sitting areas, and potted plants. There are two locked sheds with supplies, equipment, a generator, and other miscellaneous items. Both sheds are inaccessible to residents in care. Emergency food supplies and supplemental supplies are kept in a locked pantry accessed from the backyard area. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. There are no bodies of water.
Due to time restraints, LPA will return at a later date to continue the inspection.
Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC809 (FAS) - (06/04)
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