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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802101
Report Date: 02/23/2024
Date Signed: 02/23/2024 03:27:05 PM

Document Has Been Signed on 02/23/2024 03:27 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:CG HOUSEFACILITY NUMBER:
425802101
ADMINISTRATOR:NICHOLAS PAPAGEORGEFACILITY TYPE:
735
ADDRESS:224 COTTAGE GROVE AVETELEPHONE:
(805) 564-8334
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY: 6CENSUS: 5DATE:
02/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Jennifer Goddard, Co-AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection to the above-named facility. Upon arrival, LPA was greeted by Staff 1 (S1). Co-Administrator Jennifer Goddard arrived at approximately 1:00 PM.
Entrance interview conducted.
At the time of arrival, there was one staff member and five residents present. Entrance into the facility is into the living room and dining area. LPA conducted a physical tour of the facility. This is a one-story home licensed as an Adult Residential Facility (ARF) and contracted with Santa Barbara County Behavioral Wellness Program. LPA toured facility with S1.
The facility consists of a living room, dining area, kitchen, three shared bedrooms, and a locked office/meeting/medication/staff room. A washer, dryer, refrigerator, and locked cabinets are located on the patio behind the kitchen area. Bedroom #1 and Bedroom #2 are shared bedrooms. Bedroom #3 is a shared bedroom with a private bathroom. Bathroom #1 is a shared bathroom off the kitchen area for all residents.
The facility is equipped with two (2) carbon monoxide detectors. There are four (4) smoke alarms. There is one (1) fire extinguisher located in the kitchen area. The last service date was 4/20/2023. The facility has fire clearance for six (6) ambulatory residents.
A First Aid kit is located in the medication room. Sharps, emergency food, and non-perishables are kept in the staff room closet. Residents’ records, medications, personnel documents and records of confidentiality are kept in a locked file cabinet in the locked staff/medication room.
Each resident’s bedroom has a bed, mattress, nightstand, chair, dresser, and closet. Overhead lighting and lamps provide sufficient lighting in each bedroom.
The facility maintains a comfortable room temperature.

Please continue to 809-C, Pg 2

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2024
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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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: CG HOUSE
FACILITY NUMBER: 425802101
VISIT DATE: 02/23/2024
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 Residents may participate at will in various activities such as the Mental Wellness Center/
Recovery Learning Center with transportation via facility drivers and local public transit. Other activities include seasonal celebrations, house meetings, and excursions to local eateries and retail businesses. The facility has two staff who are specifically assigned to transporting residents to appointments, outings, shopping, and for back-up. Residents participate at will with day-to-day chores including personal laundry, food and meal preparation, table setting, general cleaning, and outside upkeep.
The front yard is a fenced area with planted gardens and walkways leading to the front door and sides of the facility. The backyard has a fenced area with fruit trees, paved patio with a table and chairs for outdoor seating. There are no bodies of water.
Upon inspection, walls, doors, ceilings, and floors were observed to be clean and in good order.
Residents files were reviewed for health screening, admission agreements, needs and services plans, pre-appraisal and medication records. All medications are given as prescribed.
Staff personnel records were reviewed. All staff have been properly associated to the facility with a criminal background clearance.

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: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC809 (FAS) - (06/04)
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