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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850025
Report Date: 08/20/2020
Date Signed: 08/20/2020 04:07:48 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:SANTA MARIA TERRACEFACILITY NUMBER:
425850025
ADMINISTRATOR:ENRIQUEZ, SANJUANAFACILITY TYPE:
740
ADDRESS:1405 E MAIN STTELEPHONE:
(805) 925-8713
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:140CENSUS: 5DATE:
08/20/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Sanjuana Enriquez / AdministratorTIME COMPLETED:
04:15 PM
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At 3:50pm on 08/20/2020, Licensing Program Analyst (LPA) Mark Jeffries initiated a Case Management Visit for the cross repot dated 08/17/2020 from Adult Protective Services of Santa Barbara County. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s case management visit was conducted telephonically with Sanjuana Enriquez the facility Administrator.
LPA confirmed that Resident (R1) named in the Adult Protective Services (ADP) cross report was in fact a current resident of the facility and was a resident on the date of 08/17/2020. LPA requested Physicians Report for R1, and all incident reports of R1 for the past 6 months. Administrator stated that R1 had an Eye doctors appointment with R1s Son. R1 one told eye doctor that they had been hit in the back of the neck a softball according to Administrator. R1 told a facility staff (name unknown at time of call) that R1 had been hit in the back of the neck with a stick. R1 was taken to the ER for evaluation due to her statements. According to Administrator R1 stated to the ER Physician that she was hit by an unknown staff. LPA requested contact information for R1's son and a copy of the Emergency Room visit report in full.



Report emailed to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020
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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