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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850001
Report Date: 03/22/2021
Date Signed: 03/22/2021 07:34:01 PM

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:VILLA ALAMARFACILITY NUMBER:
425850001
ADMINISTRATOR:LEICHTER, MITCHFACILITY TYPE:
740
ADDRESS:45 E ALAMAR AVETELEPHONE:
(805) 682-9345
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY:43CENSUS: 18DATE:
03/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Mitch LeichterTIME COMPLETED:
01:06 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a case management investigation telephonically with Administrator Mitch Leichter due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures.

On 3/17/21 LPA received a telephone call from staff #1 (S1) reporting that resident #1 (R1) eloped from the facility that morning. S1 stated that staff had observed R1 10 minutes prior to R1 eloping. S1 stated that staff searched for R1 and called 911. R1 was found by police approximately 1.5 miles away from the facility on 3/17/21 without any injury. S1 stated that R1’s family was contacted and R1 was placed with a 1:1 caregiver until R1’s family picked R1 up from the facility approximately 2 hours later. S1 stated that their maintenance staff checked all exits of the facility to ensure that they were secure. S1 stated that they do not know how R1 was able to elope from the facility.

LPA reviewed R1’s records on 3/19/21 starting at approximately 11:45 am which revealed that R1 is not able to leave the facility unassisted, has poor safety awareness, needs frequent one-on-one attention and wanders off.

During today’s visit LPA toured the facility with S1 and interviewed the Administrator. Interview with Administrator on 3/22/21 at 12:53 pm revealed that the facility does not have an Admission Agreement on file for R1. Based on information obtained during the investigation staff failed to supervise R1 on 3/17/21 as R1 eloped from the facility and the facility failed to ensure R1 had an Admission Agreement on file.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



A telephonic exit interview was conducted with the Administrator, and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA ALAMAR
FACILITY NUMBER: 425850001
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/23/2021
Section Cited

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87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
This requirement is not met as evidenced by:
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Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted which poses an immediate health and safety risk to persons in care.
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Type B
03/29/2021
Section Cited

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87507 Admission Agreements. (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.


This requirement is not met as evidenced by:
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Based on interview with Administrator, the licensee failed to ensure that they had a signed admission agreement for R1 which posed a potential personal rights risk to resident’s 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2021
LIC809 (FAS) - (06/04)
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