425802124-11-9-2023-29-AS-JOLN-CXEU5L-20231109141654

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802124
Report Date: 11/09/2023
Date Signed: 11/09/2023 02:17:06 PM

Document Has Been Signed on 11/09/2023 02:17 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:	ST. ANDREW'S RESIDENCE 1		FACILITY NUMBER:	425802124
ADMINISTRATOR:	ABATA, CHARMAINE		FACILITY TYPE:	735
ADDRESS:	1913 BIRCH STREET		TELEPHONE:	(805) 937-8273
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY: 6		CENSUS: 6	DATE:	11/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Angie Pimentel, Assistant Administrator		TIME COMPLETED:	02:20 PM

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Licensing Program Analysts (LPA) Jenny Olson arrived unannounced to conduct a one year required annual inspection. LPA met with Assistant Administrator and explained the reason for the visit.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The facility has a sufficient supply of non-perishable and perishable food items. Cleaning supplies and disinfectants are stored in the garage, inaccessible to clients. Knives are stored in a locked cabinet in the kitchen. Around 2:00 p.m., the hot water temperature measured in the kitchen at 119.7 degrees Fahrenheit.

Common areas: Living and dining room furniture were observed to be in good condition. At 11:30 a.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced 7/6/2023.

The backyard has a outdoor area equipped with furniture for client use. Administrator agreed to get an umbrella for shade. No bodies of water noted. The washer and dryer are in the laundry room next too the garage. The garage is not locked.

Restrooms: The three (3) client restrooms were clean and sanitary and in operating condition with non-skid mats. The bathrooms were sufficiently stocked with soap and paper towels.

Bedrooms: There are four (4) client rooms, which were furnished with appropriate linens and required furniture. A linen closet was located outside of the rooms, which stocked extra linens and towels.

Records: LPA reviewed client and staff records at 10:40 a.m. LPA reviewed five (5) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and needs and services plan. All files were complete. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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: ST. ANDREW'S RESIDENCE 1	FACILITY NUMBER: 425802124
	VISIT DATE: 11/09/2023

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LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 3 home. The last disaster drill was conducted on 9/26/2023.

Medications: Medications review began at 12:30 p.m.; medications are centrally stored and locked in a closet next to the entrance. Medications are labeled and checked for expiration dates. LPA advised the Administrator to ensure that all the necessary information is properly documented on the CSMDR.

Infection Control: The facility has an infection control plan The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is adequate. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Around 12:50pm LPA interviewed two (2) Staff and two (2) clients.

Exit interview conducted. A copy of the report was printed and emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC809 (FAS) - (06/04)

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