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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802124
Report Date: 08/22/2024
Date Signed: 08/22/2024 05:32:13 PM

Document Has Been Signed on 08/22/2024 05:32 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:
08/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Charmaine AbataTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Miller and Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Miguel Magaña conducted a follow up visit to deliver final findings for an incident that occurred on 08/8/2024. LPA and QAS interviewed additional residents and staff on 8/22/24.

R1 made many hand gestures, but communication was not possible. LPA stated each staff member by name and R1 pointed to a happy face indicating that he did not feel unsafe.

4 of 4 residents indicated that staff are not hitting or pushing and staff are treating residents well.

No deficiencies were issued. 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: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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