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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802124
Report Date: 08/21/2024
Date Signed: 08/21/2024 02:07:14 PM

Document Has Been Signed on 08/21/2024 02:07 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ST. ANDREW'S RESIDENCE 1FACILITY NUMBER:
425802124
ADMINISTRATOR/
DIRECTOR:		ABATA, CHARMAINEFACILITY TYPE:
735
ADDRESS:1913 BIRCH STREETTELEPHONE:
(805) 937-8273
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 6CENSUS: 6DATE:
08/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Charmaine Abata, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Erika Miller was accompanied by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Miguel Magaña to conduct an unannounced on-site visit to the facility related to an incident that occurred on 8/8/2024.

LPA and QAS met with Administrators, Charmaine Abata and Angie Pimentel and explained the purpose of the visit. LPA and QAS interviewed Administrators regarding the incident and discussed best practices related to change of condition protocol. LPA and QAS also interviewed residents.

On 8/8/24 Resident 1 (R1) showed Staff 1 (S1) lower abdomen with 6-7 little dark spots. R1 indicated that it did not hurt, and no trauma was observed by staff. S1 notified administrator, but no documentation was kept or provided. Administrator advised S1 to monitor R1 for changes, S1 did not believe marks were evidence of bruising. The following day S1 did not notice any changes as R1 bathed himself and went to a medical appointment.

On 8/9/24 Staff 2 (S2) transported R1 to medical appointment. Administrator stated that a social worker called to advise that bruises of unknown original were observed on R1. Administrator stated that they spoke with a nurse who advised it was an unusual kind of bruise and suggested it may have been a side effect of a change in medication. However there have been no changes to R1 medication. Administrator interviewed R1, who communicated that they went to doctor’s office and does not know how bruises appeared. R1 went to a medical appointment and day program on 8/7/24 and 8/8/2024, respectively and no incidents were reported. Administrator does not have any documentation from social workers, medical providers, or any notes from interview with R1.


(Continued on 809-C)
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ST. ANDREW'S RESIDENCE 1
FACILITY NUMBER: 425802124
VISIT DATE: 08/21/2024
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2 of 2 Residents stated that they feel safe, and that staff are nice. 2 of 2 residents stated that staff does not hit, push or yell at them.

Administrator agreed to hold a meeting for staff to review change of condition protocosl. Administrator will ensure that best practices are followed by documenting all aspects of unusual incidents.

By 8/10/2024 the bruise changed to brown in color. R1 had medical appointment on 8/20/2024 for vascular checkup but did not address the bruising. Administrator will discuss R1 incident with Nephrologist on 8/22/24 and R1 will have follow up with primary care physician on 8/29/2024.

No deficiencies issued, but LPA and QAS may return if CCL deems it necessary.


Exit interview conducted and a copy of the report printed for administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2