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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802124
Report Date: 05/10/2023
Date Signed: 05/10/2023 04:47:32 PM

Document Has Been Signed on 05/10/2023 04:47 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 1FACILITY NUMBER:
425802124
ADMINISTRATOR:ABATA, CHARMAINEFACILITY TYPE:
735
ADDRESS:1913 BIRCH STREETTELEPHONE:
(805) 937-8273
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 6CENSUS: 6DATE:
05/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Charmaine Abata, Administrator/LicenseeTIME COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Olson conducted an unannounced Case Management- Incident visit to the facility above. LPA was accompanied by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Miguel Magana. LPA and QAS met with Administrator and explained the purpose of the visit.

CCL received an incident report on 05/01/23 stating that on 05/01/23 Client 1 (C1) showed staff a bruise on their left side/lower back area that was around 6 inches long and that it hurt. LPA and QAS interviewed staff who stated when they asked what happened at first C1 said nothing, they didn’t fall or know how they got the bruise. A day or two days later C1 stated Staff 1 (S1) hit them. C1 also said another staff’s name and a client’s name but it wasn’t clear how they were involved. Staff stated C1 has limited vocabulary so it’s hard to know exactly what happened. LPA and QAS interviewed staff about the bruise. Some staff stated C1 sits down really fast and might have gotten the bruise from their armchair. Other staff says C1 sits down normal and isn’t sure how they got the bruise. A few staff stated that some Clients have said they don’t like S1. Staff mentioned that S1 is loud and yells in loud voice and tells clients to “get out”, “go there”, “go pee”. Administrator stated they’ve talked to S1 about this and to lower their voice and it gets better but then S1 goes back to using a loud voice. Administrator put S1 on leave while they investigated the incident.

Interview with Clients revealed clients are scared of S1 think their mean and they yell all the time. A client stated S1 says a bad word to and around clients. Client also stated S1 takes their stuff, throws away their print outs and broke their clock radio. Clients also stated S1 doesn’t allow them to sit on the staff couch. Client 1 stated "I got hit" LPA asked with what? "fist" "one time". When? Monday (S1) hit me.

LPA and QAS interviewed Staff 1 (S1) who stated they love all the clients and would never hit or hurt anyone. Staff admitted to having a loud voice and telling C1 to get out of the kitchen and go back to the living room for their safety while cooking. Staff said they can work on their voice and lower it and wants to go back to work.
Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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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Document Has Been Signed on 05/10/2023 04:47 PM - It Cannot Be Edited


Created By: Jeannette Olson On 05/10/2023 at 03:54 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: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2023
Section Cited
CCR
80072(a)(1)

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80072 Personal Rights (a)...each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by:
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Administrator agreed to schedule a training with all staff on personal rights and send the date to CCL by 5/11/23. Administrator also agreed to send a copy of the training to CCL with name, dates, topics covered and staff signatures.
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Based on interviews, the licensee did not comply with the section cited above when Staff 1 did not treat clients with dignity, which posed an immediate health and safety/personal rights risk to residents 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:Jeannette Olson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


LIC809 (FAS) - (06/04)
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