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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802106
Report Date: 11/08/2024
Date Signed: 11/12/2024 08:46:15 AM

Document Has Been Signed on 11/12/2024 08:46 AM - 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:WESTMONT OF SANTA BARBARAFACILITY NUMBER:
425802106
ADMINISTRATOR/
DIRECTOR:		ERNEST "EJ" LEWISFACILITY TYPE:
740
ADDRESS:190 VIAJERO DRTELEPHONE:
(805) 265-4327
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 99CENSUS: 68DATE:
11/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Ernest "EJ" Lewis, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-20241104104759 investigation visit conducted on 11/8/2024.

At approximately 11:21 am during a tour of the facility, LPA observed the carpet in a resident’s room is stained and soiled. Administrator stated on 10/22/2024, he learned from the Residents’ Council meeting that there are five residents’ rooms that need carpet cleaning service.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiency may result in additional civil penalties.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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 11/12/2024 08:46 AM - It Cannot Be Edited


Created By: Kristin Kontilis On 11/08/2024 at 03:26 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: WESTMONT OF SANTA BARBARA
FACILITY NUMBER: 425802106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
87303(a)

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87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times…

This requirement is not met as evidenced by:
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Administrator agrees to have carpets cleaned in five (5) resident's rooms no later than POC due date (11/15/2024). Administrator agrees to provide photographs of cleaned carpets via email on or before POC due date (11/15/2024).
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Based on observation, the licensee did not comply with the section cited above as the carpet in a resident’s room was observed to be stained and soiled which poses/posed a potential health, safety, or personal rights risk to persons 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:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
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