425802124-10-16-2024-29-AS-EMIR-DA4RDM-20241016125609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802124
Report Date: 10/16/2024
Date Signed: 10/16/2024 12:56:21 PM

Document Has Been Signed on 10/16/2024 12:56 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 1		FACILITY NUMBER:	425802124
ADMINISTRATOR/ DIRECTOR:	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:	10/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:40 AM
MET WITH:	Angeles Pimentel, Asst. Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Erika Miller arrived at 8:40 a.m. to conduct a 1-year required annual visit. LPA met with Angeles Pimental, Assistant Administrator. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has at least a 30-day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environment Safety: LPA toured resident rooms and observed that rooms were tidy, the lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. The facility has sufficient space inside and outside for activities and visiting. The facility has telephone and internet service for resident use. Thefire extinguisher was last charged and inspected on 7/8/24. The facility has a carbon monoxide and smoke detector that were tested and working. LPA observed that bleach and disinfectants were left unlocked in the garage and the door was open. LPA notified staff who immediately placed a pad lock on the cabinet, but did not secure the lock. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

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 4

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: 10/16/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 6. The fire clearance is granted for 6 non-ambulatory.

Staffing: The facility currently employs 6 staff and 1 administrator. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians report,s Pre-appraisals, IPPs, Emergency and ID forms. All forms were legible.

Food Service:. The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored, and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies.

Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, no medications were expired, and all medications were kept in their original containers.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Exit interview conducted and copy of report printed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/16/2024 12:56 PM - It Cannot Be Edited

Created By: Erika Miller On 10/16/2024 at 12:49 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: ST. ANDREW'S RESIDENCE 1	FACILITY NUMBER: 425802124
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above, when cleaning solutions were left unlocked which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/23/2024
	Plan of Correction
1 2 3 4	Administrator agreed to remind staff to keep disinfectants and cleaning solutions and other items that could pose a danger, locked in cabinet. Administrator agreed to submit state of understanding with staff signatures.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Erika Miller

LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4